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A REFERENCE HAND-BOOK 



OF 



GYNECOLOGY 



FOR NURSES 



BY 



CATHARINE ^lACFARLANE, M. D. 

Gynecologist to the Woman's Hospital of Philadelphia 



ILLUST RATED 

Second Edition, Thoroughly Revised 



PHILADELPHIA AND LONDON 

W. B. SAUNDERS COMPANY 

1913 






Copyright, 1908, by W. B. Saunders Company. Revised, 
reprinted, and recopyrighted May, 1913 



Copyright, i9i3,by W. B. Saunders Company 






PRINTED IN AMERICA 



PRESS OF 

W. B. SAUNDERS COMPANY 

PHILADELPHIA 



"©CI.A847861 






THIS LITTLE BOOK 

IS AFFECTIONATELY DEDICATED 

TO MY MOTHER AND FIRST TEACHER, 

NETTIE O, MACFARLANE 



PREFACE TO SECOND EDITION 



The principal changes in this edition pertain 
to details of technic — dry sterilization of gloves 
is described, and the iodin preparation of the 
skin; the sections on the preparation for and" 
after-care of major gynecologic operations have 
been largely rewritten, and numerous changes 
have been made throughout the book to con- 
form with the present methods. 

Additions to the text will be found under 
cancer of the uterus, vaginofixation, and acute 
gastric dilatation. Three new illustrations have 
been added. 

Catharine Macfarlane 

1709 Pine Street, Philadelphia, Pa. 
May, 1913. 



PREFACE 



lectures on Gynecology which it is my custom to 
deliver each year to the nurses of the Woman's 
Hospital of Philadelphia. 

The preparation for operation, operative tech- 
nic, and post-operative treatment described in 
it follow the routine instituted by my chief, Dr. 
Caroline M. Purnell. 

I am indebted to Miss Bertha M. Seldomridge 
and Miss Bess McCormick, surgical supervisors, 
for details of treatment and operating-room tech- 
nic; to Mrs. Isabel Close, head nurse, for a care- 
ful revision of the manuscript; and to my friend, 
Dr. Mary P. S. Rupert, for helpful criticism from 
beginning to end. 

I take this opportunity to thank my publishers, 
Messrs. W. B. Saunders Co., for their cordial 
cooperation. 

Catharine Macfarlane 



V 



CONTENTS 



PAGE 

Anatomy , 1 1 

Physiology and Hygiene 20 

Disorders of Menstruation 22 

Gynecologic Examination 22 

Gynecologic Positions 27 

Douches 31 

Gynecologic Diseases 37 

Gynecologic Treatment 52 

Minor Gynecologic Operations 56 

Major Gynecologic Operations 77 

Urinary Organs of Women 117 

Rectum and Its Diseases 133 

Index 149 

9 



Gynecology for Nurses 



ANATOMY 



The Pelvis. — The pelvis (Fig. i) is a bony 
girdle situated at the middle of the body in adults. 
It receives the weight of the trunk and transmits it 
to the lower extremities. In the female it serves 




Pubic Symphysis 
Fig. i. — The pelvis. 

ilso to support and protect the internal organs of 
meration. 

Four bones compose the pelvis: two innominate 
bones, the sacrum, and the coccyx. 

At birth each innominate bone (Fig. 2) consists 
of three separate bones, called the ilium, the 
ischium, and the pubis. These unite at thirteen 
to fifteen years to form one large irregular bone. 

The ilium is the upper expanded portion of the 
innominate bone; its upper border is a thick ridge 



12 



GYNECOLOGY FOR NURSES 



which forms the prominence of the hip and gives 
attachment to the muscles of the abdominal wall. 
The outer surface of the ilium gives attachment 
to the large muscles of the buttocks. The inner 
surface is smooth and concave, forming the iliac 
fossa. 

The ischium is the lower and posterior portion 
of the innominate bone. The body rests upon the 
tuberosities of the ischium in the sitting posture. 



Jschi 




Wtabulufn, 



Tuberosity of Ischium^ 

Fig. 2. — The innominate bone. 



The pubic bone is the anterior portion of the 
innominate bone. The two pubic bones unite 
to complete the pelvis anteriorly. Their articula- 
tion is called the pubic symphysis. 

On the outer surface of the innominate bone 
is a cup-shaped articular cavity, the acetabulum, 
which receives the head of the femur. 

The sacrum (Fig. 3) is a wedge-shaped bone 
which completes the pelvis posteriorly. It is 
traversed by a central canal, which lodges the 
sacral nerves. These nerves pass out through 
openings on the anterior and posterior surfaces of 



L 



ANATOMY 



13 



the bone. The anterior surface is smooth and con- 
cave; it is called the hollow of the sacrum. The 
posterior surface is rough, and presents spines and 
processes for the attachment of muscles and liga- 
ments. 




Fig. 3. — The sacrum. 

On each side the bone bears a large smooth 
surface for articulation with the ilium. The base 
of the sacrum articulates with the last lumbar 
vertebra to form an angle called the promontory 
of the sacrum. 




Fig. 4. — Coccyx. 



In the child this bone consists of five separate 
vertebrae which unite at fifteen to eighteen years. 

The coccyx (Fig. 4) is a rudimentary bone which 
forms the tip of the vertebral column. Injury to 
this bone by falls, blows, or forceps delivery may 
cause a very painful affection called coccygodynia. 
Excision of the bone is the only cure. 



14 GYNECOLOGY FOR NURSES 

The Female Generative Organs. — The female 
generative organs are divided into three groups: 
the external, the internal, and the intermediate. 

The external organs of generation are known 
collectively as the vulva (Fig. 5) , and comprise the 
mons veneris, labia majora, labia minora, clitoris, 
vestibule, meatus urinarius, hymen, vaginal ori- 
fice, navicular fpssa, and posterior commissure or 
fourchet. 







.V. 



Fig. 5. — Diagram of female external genitals (Dickinson). 

The mons veneris is a mass of fatty tissue over- 
lying the pubic bones; it is covered with hair-clad 
skin, and, in the upright position, conceals the 
remaining structures of the vulva. 

The labia majora are two thick folds of hair-clad 
skin extending from the mons veneris to the 
posterior commissure. 



ANATOMY 15 

The labia minora, or nymphae, are two folds of 
delicate skin inclosing venous plexuses; they arise, 
one on each side, from the inner surface of the 
labia majora, and meet in the median line ante- 
riorly to form the support and covering of the 
clitoris. 

The clitoris consists of erectile tissue covered 
with mucous membrane; it is highly sensitive, 
and must not be touched in manipulations about 
the vulva. 

The vestibule is a triangular area of mucous 
membrane lying between the labia minora on each 
side, the clitoris in front, and the vaginal orifice 
posteriorly. 

The meatus urinarius, or the external urethral 
orifice, is situated in the center of the vestibule. 

In the virgin the vaginal orifice is more or less 
completely closed by the hymen, a thin fold of 
mucous membrane inclosing a little fibrous tissue 
and a few blood-vessels. The hymen may be 
crescentic, annular, cribriform, or imperforate. 
On each side of the hymen a minute orifice can be 
found — the external opening of the duct of the 
Bartholinian gland. The duct is about half an 
inch long, and the gland is about the size of a 
horse-bean; it is situated at the side of the vagina. 
After child-birth the hymen is converted into a 
few shapeless masses — the carunculae myrtiformes. 

In all manipulations about the vulva the integrity 
of the hymen must be carefully preserved. 

The navicular fossa is a slight depression 
between the hymen and the posterior commissure 
or fonrchet, a fold of tissue which limits the 
vulva posteriorly. This fossa is frequently the 
seat of the primary sore of syphilis, and should 
always be inspected before touching the vulva. 
That portion of the pelvic floor situated between 
the posterior commissure and the anus is termed 
the perineum. 



i6 



GYNECOLOGY FOR NURSES 



The intermediate organ of generation is the 
vagina. This is a musculomembranous canal 
which connects the vulva with the uterus. 

The walls of the vagina lie closely applied. 
The anterior wall is in relation with the urethra 
and base of the bladder; the posterior wall, with 
the perineal body, rectum, and peritoneum. 

The mucous membrane lining the vagina is 
thrown into folds and is covered with many layers 
of squamous epithelium; it contains no glands. 
The vagina is the normal habitat of the lactic-acid 
bacillus of Doderlein; this bacillus gives to the 
vaginal secretion its acid reaction and germicidal 






BectufttL. 




jBlad&er 



Fig. 6. — Sagittal section, showing normal position and relation 
of uterus, bladder, and rectum. 



properties. Cultures of the ordinary pus-producing 
organisms introduced into the vagina are soon 
rendered harmless. 

At its upper part the vagina is attached to the 
neck of the uterus. 

The internal organs of generation comprise 
the uterus, the Fallopian tubes, and the ovaries. 



ANATOMY 17 

The uterus (Fig. 6) is a pear-shaped organ with 
thick muscular walls inclosing a narrow cavity. In 
the virgin it measures three inches long, one and 
one-half inches wide, and one inch thick. The 
organ is divided by a circular depression, the 
isthmus, into, an upper, triangular portion, the 
body; and a lower, spindle-shaped portion, the 
neck or cervix. The vagina is attached to the 
cervix a little below the isthmus. 

The anterior surface of the uterus rests upon 
the bladder. The upper border, which is broad 
and thick, is called the fundus. The junction of 
each lateral border with the fundus is called a 
cornu. 

At the lower angle of the uterus 'is the external 
uterine orifice. In the virgin this is a narrow, 
transverse slit; after child-birth it becomes circular 
or, if torn, gives rise to lateral, bilateral, or stellate 
lacerations of the cervix. 

Internally the cavity of the uterus is divided, on 
a level with the isthmus, into an upper, triangular 
portion, the cavity of the body, and a lower cylin- 
dric portion, the cervical canal. The cavity of 
the body communicates with the cervical canal 
through the internal uterine orifice; it communi- 
cates with the cavity of the Fallopian tubes through 
a small orifice in each cornu. 

The mucous membrane lining the cavity is 
thick and vascular; it contains numerous glands 
which secrete an alkaline mucus. The muscular 
coat of the uterus is very thick and vascular. 

The uterus is held in position by ligaments; 
these are folds of peritoneum inclosing some 
muscular and fibrous tissue. The broad ligaments 
extend from the sides of the uterus to the pelvic 
wall; the round ligaments, from the cornua to the 
internal abdominal rings; the uterosacral ligaments, 
from the cervix to the hollow of the sacrum; and 
the uterovesical ligaments, from the cervix to the 
symphysis pubis. 



i8 



GYNECOLOGY FOR NURSES 



The oviducts or Fallopian tubes (Figs. 7 and 8) are 
two in number, and extend from the cornua of the 
uterus along the upper border of the broad liga- 
ments. 

Each oviduct is from four to five inches long, 
and commences as a narrow straight tube, called 
the isthmus; this passes into a wider and tortuous 
portion, the ampulla, which finally expands into 



fTiy onciu^ 



tube 



Gtnafutn. 

follicle 




External uterine orifice 



Cowity ofthe$Oi 



Co-"*-*- 0/ FcUlofita.H,tlcb* 




Figs. 7 and 8. — The uterus, ovary, and Fallopian tube. 



the dilated infundibulum, a trumpet-shaped orifice 
surrounded by finger-like processes called fimbriae. 
The oviduct contains a canal lined with mucous 
membrane. 



ANATOMY 19 

The ovaries, two in number, are almond-shaped 
bodies attached to the posterior surface of the 
broad ligaments. They contain innumerable ova, 
each one surrounded by a more or less well- 
developed cellular envelop, which is called a 
Graafian follicle when mature. The follicle pro- 
jects upon the outer surface of the ovary, and, 
when ripe, ruptures and discharges the ovum into 
the Fallopian tube" After rupture the follicle 
degenerates and is converted into a yellow scar 
or corpus luteum. 



1 



PHYSIOLOGY AND HYGIENE 

The functions of the female generative organs 
are ovulation, menstruation, conception, preg- 
nancy, and parturition. 

Ovulation is the ripening and discharge of ova. 
At birth each ovary contains from 30,000 to 40,000 
ova. The liberation of ova usually coincides 
with the menstrual periods, although the process 
is continuous throughout the child-bearing period. 

Menstruation is a discharge of blood from the 
genitalia recurring periodically from puberty until 
the menopause, except during pregnancy and 
lactation. As a rule, the flow occurs every twenty- 
eight days and lasts five to seven days. The 
discharge comes from the mucous membrane 
lining the uterus, and consists of blood mixed 
with mucus; from four to seven ounces are lost 
during the average period. 

The age at which menstruation is established is 
called the age of puberty; it averages about fourteen 
years in this country, and coincides with the first 
regular liberation of ova. The changes of puberty 
include the development of the pelvic bones, 
reproductive organs, and breasts; the growth of 
pubic and axillary hair; general rounding out of 
the body and maturing of the nervous system. 
As these changes are completed the girl develops 
into a woman and the child-bearing age is reached. 

The period of cessation of menstruation is called 
the menopause; this occurs usually between forty 
and fifty years, and may be abrupt or gradual; the 
underlying cause is the cessation of ovarian 
activity. The menopause is attended by atrophy 



PHYSIOLOGY AND HYGIENE 21 

of the pelvic organs and breasts, and by nervous 
phenomena, such as headaches and "flashes of 
heat." At this period malignant degeneration 
— cancer — is prone to develop in the uterus and 
breasts. 

Hygiene.— The Hygiene of Puberty.— A per- 
fectly healthy girl, who menstruates regularly and 
painlessly, requires no special oversight. She 
should be warned against exposure to cold and wet. 
Excessive exercise, dancing, golf, tennis, bicycling, 
and horseback riding during the period should be 
forbidden. 

A girl who menstruates too frequently, exces- 
sively, or with pain, must rest in bed for the first 
three days of her period or throughout the entire 
flow, and should seek medical advice to correct 
the underlying cause of her symptoms. 

The Hygiene of Maturity. — The menstruating 
woman should guard against exposure; should 
avoid heavy work or lifting; and should keep off 
her feet as much as possible during the first three 
days of the flow. 

The Hygiene of the Menopause. — The danger 
of malignant degeneration at this period is great, 
and its development most insidious. Hence every 
woman who notices " lumps" in her breast should 
be alert to consult her physician; while irregular 
or excessive bleeding from the uterus, or a return 
of bleeding after complete cessation, is a serious 
symptom and calls for immediate pelvic examina- 
tion. 

Every woman who has borne children should 
be examined after the child-bearing period. If 
lacerations of the cervix are discovered, they 
should be repaired, because they predispose to 
cancer. 

The ideal treatment for the nervous symptoms 
of the menopause is an outdoor life, with rest and 
freedom from responsibility. 



THE DISORDERS OF MENSTRUATION 

Amenorrhea is the absence of the menstrual 
flow during the period of sexual maturity. It is 
caused by exposure to cold and wet; acute infec- 
tious diseases; some chronic wasting disorders, 
such as tuberculosis, nephritis, and anemia; poor 
development and premature atrophy of the pelvic 
organs. Physiologic amenorrhea occurs during 
pregnancy and lactation. 

Dysmenorrhea is painful menstruation. It may 
be caused by disease of the pelvic organs, such as 
inflammation, displacements, or tumors. It may 
also be a symptom of hysteria or neurasthenia. 

Menorrhagia is excessive uterine bleeding at the 
regular period. Metrorrhagia is excessive bleeding 
between the periods. 

The causes of menorrhagia and metrorrhagia 
are incomplete abortion, pelvic congestion or 
inflammation, tumors of the uterus, diseases of 
the blood, systemic poisons, sclerosis of the uterine 
arteries, and valvular heart disease. 

THE GYNECOLOGIC EXAMINATION 

Prepare for the physician a basin of hot water, 
nail-brush, and soap; a basin of bichlorid solution 
i : 10,000; a pair of sterile rubber gloves; sterile 
white vaselin or glycerin as a lubricant. 

Instruments required (Fig. 9) : 

Two bivalve specula (one virgin size). 

Sims speculum. 

Weight speculum. 

Vaginal retractor. 

Tenaculum forceps. 






THE GYNECOLOGIC EXAMINATION 



23 



Uterine sound. 

Bladder sound or catheter. 

Dressing forceps. 

Applicators. 

Boil the instruments in soda 
minutes, lift them out into an 
and cover with a sterile towel, 
so desires, pour hot sterile water over the instru- 
ments when they are to be used. Never let the 
patient see the instruments. 



solution for five 
instrument tray, 
If the physician 




Fig. 9. — Instruments required for gynecologic examina- 
tion: 1, Bivalve specula; 2, Sims's speculum; 3, weight spec- 
ulum ; 4, vaginal retractor; 5, tenaculum forceps; 6, uterine 
sound ; 7, dressing forceps ; 8, applicators. 



Supplies. — Have ready in suitable receptacles 
the following supplies (Fig. 10) : 

Tampons of non-absorbent cotton or wool. 

Cotton balls. 

Cotton-wound applicators. 

How to Make a Vaginal Tampon. — Take a thin 
layer of cotton or wool about eight inches long and 
three and a half inches wide, fold over each long 
edge to the center. Fold one end down to meet 
the other end, and tie a piece of linen thread, six 
inches long, around all layers of the tampon, about 
half an inch from the cut end. 



24 



GYNECOLOGY FOR NURSES 



Prepare tampons of different widths and lengths; 
thick tampons are not desirable. 

Preparation of the Patient. — Clothing. — In 
office practice, tell the patient to remove her hat 
and coat, loosen all bands about the waist, and to 
take off her corset. Closed drawers must be taken 
off. 

If the patient is in bed, provide a pair of drawers 
and stockings for her to wear in addition to her 
gown. 

Bowels. — The patient's bowels must be thor- 
oughly emptied by a low soap-suds enema, given 
at least one hour before the examination. 




I 



Fig. 10. — Tampon, cotton balls, and cotton- wound applicators. 



Bladder. — Direct the patient to empty her 
bladder immediately before the examination. 

Cleansing and Disinfection. — Wash off the 
vulva and perineum with warm water and soap, 
and give a cleansing vaginal douche of salt or 
boric-acid solution before the examination. 

If an extensive examination is planned, including 
passing the uterine or bladder sound, disinfect 
the vulva with bichlorid solution i : 10,000 after 
the soap-and-water cleansing, and give a bichlorid 
vaginal douche. 



THE GYNECOLOGIC EXAMINATION 



25 



In some cases the physician may prefer to 
examine the patient without preliminary cleansing 
or disinfection, in order to determine the presence 
and character of certain discharges. 

Preparation of the Table. — Pelvic examina- 
tions are usually made upon a gynecologic treat- 
ment table. 

For the examination the nurse must provide two 
pillows and two sheets. Cover the table with one 
sheet, place one or more pillows for the patient's 
head, and drape the second sheet over the patient's 
body to prevent unnecessary exposure. 




Fig. 11. — Patient in the dorsal position, lengthwise in the bed 
(Ashton). 

Treatment table sheets measure one yard wide 
by two yards long. An ordinary kitchen table 
provided with adjustable foot-rests or stirrups 
may serve instead of a complicated treatment 
table. 

Preparation of the Bed. — If the patient is to 
be examined in bed, provide an extra sheet and a 
suitable board that will support the patient and 
prevent her hips from sagging down into the 
mattress. In private houses a lap-boaid, the 
leaf of a dining-table, or an ironing-board serves 
the purpose. 

The patient may be examined lying either length- 
wise or crosswise of the bed. 



26 



GYNECOLOGY FOR NURSES 



The lengthwise position is used only when the 
patient is too ill to be disturbed; instruments 
cannot be used in this position, and it is available 
only for inspection of the vulva and for digital 
examination. 

To prepare for examination in this position slip 
the board between the mattress and the wire 
spring at right angles to the side rail of the bed; 
draw up the patient's knees and separate them 
widely; flex her thighs and legs, and place her 
feet at the edge of the board, about twelve inches 
apart (Fig. n). Turn the bed-clothes back 




Fig. 



12. — Patient in the dorsal position, crosswise in the bed 
(Ashton). 



neatly and drape a sheet over the patient's body 
and knees, arranging it so as to expose the vulva. 
The Cross-bed Position (Fig. 12). — To prepare 
for examination in this position slip the board 
under the mattress lengthwise of the bed and 
close to the side rail. Place the patient across the 
bed with her head on pillows, her hips on the 
board, her knees drawn up and widely separated, 
and her feet on foot-rests or on two chairs placed 
eighteen inches apart, touching the side rail of 
the bed. 



THE GYNECOLOGIC POSITIONS 

The following positions are used in gynecologic 
examination and treatment: 

Standing position. 

Dorsal position. 

Elevated dorsal position. 

Lithotomy position. 

Knee-chest, knee-breast, or genupectoral posi- 
tion. 

Sims's or left lateroprone position. 

Horizontal recumbent position. 

Trendelenburg position. 




Fig. 13. — Standing position (Ashton). 



Standing Position (Fig. 13). — In this position 
the patient stands near a chair or table, with one 
foot on the floor and the other resting on a stool 



27 



28 



GYNECOLOGY FOR NURSES. 



or on the round of a chair, six or eight inches from 
the floor. She steadies herself by resting one 
hand upon the table or chair-back. 

Roll the patient's skirts up in front and pin 
them at the waist-line in the back. Pin a sheet 
around the patient's waist, reaching to the floor 
and opening at one side. 

Dorsal Position (Fig. 14). — In this position 
the patient lies on her back, with her hips at the . 
edge of the table and her feet resting upon foot- 
rests; her thighs are flexed upon the abdomen and * 
her legs upon the thighs. 




Fig. 14. — Dorsal position (Ashton). 



Tell the patient to raise her skirts in the back 
before sitting down upon the table. After she is 
in position throw a sheet over her lower extremities 
and abdomen. Grasp with both hands the lower 
edge of the patient's skirts in front, gather them up 
into folds, and carry them above her knees. 

Fold the lower edge of the sheet between her 
thighs to expose the vulva, and drape one end 
across to the opposite knee to prevent exposure 
until the examiner is ready to proceed. 

Elevated Dorsal Position. — This position 
resembles the preceding except that the patient's 



THE GYNECOLOGIC POSITIONS 



2 9 



head and shoulders are elevated on several pil- 
lows. 

Lithotomy Position (Fig. 15). — This position 
is similar to the dorsal position except that the 




Fig. 15. — Lithotomy position (Ashton). 

patient's feet rest in stirrups about eighteen inches 
above the level of the table. 

Knee-chest Position (Fig. 16). — In this posi- 
tion the patient kneels on the table, near one 




Fig. 16. — Knee-chest position (Ashton). 



end, with her knees slightly separated, her feet 
projecting over the edge of the table, and her 
thighs vertical. Her face is turned on one side 
and rests upon a soft pillow. The patient touches 
the table with her breasts and knees and grasps 



30 GYNECOLOGY FOR NURSES 

the sides of the table with her hands. A folded 
pillow may be placed under her chest for support. 

Throw a sheet over the patient's hips, push the 
skirts up beyond the hips, and separate the sheet 
to expose the gluteal cleft. 

Sims's Position. — In this position (Fig. 17) 
the patient lies on her left side with the left hip at 




Fig. 17. — Sims's position (Penrose). 

the edge of the table and her left arm behind her. 
Both knees are drawn up toward her chest; the 
right knee rests upon the table in front of the left 
knee. Drape a sheet over the patient's lower 
limbs and abdomen, push the clothing up above 
the hips, and separate the edges of the sheet to 
expose the gluteal cleft. 




Fig, 18. — Horizontal recumbent position (Ashton). 

Horizontal Recumbent Position. — In this 
position (Fig. 18) the patient lies flat upon her 
back, with her head resting upon a pillow, her 
arms alongside the body, legs extended, and heels 
in contact. 



DOUCHES 



31 



Push the patient's clothing well below the hips, 
both back and front, and cover her lower limbs 
with a folded sheet. Push the clothing of the 
upper part of the body well above the waist-line, 
fold a second sheet and lay it across the chest and 
arms. The surface of the abdomen is exposed to 
view. 

Trendelenburg Position. — In this position 
(Fig. 19) the patient lies flat upon her back upon 




Fig. 19. — Trendelenburg position (Ashton). 

an inclined plane in such a way that her knees are 
at the highest point and her feet hang over the 
edge of the plane. 

Arrange the clothing and sheets as in the pre- 
ceding position. 



DOUCHES 

A douche is a stream of water directed against 
a part or used to flush a cavity of the body. 
Vaginal and intra-uterine douches are used in 
gynecology. 

Vaginal Douches. — Vaginal douches are given 
for various purposes — cleansing, disinfection, de- 
pletion, to allay irritation, to shrink relaxed tissues, 
and to arrest hemorrhage. 



32 



GYNECOLOGY FOR NURSES 



Articles Needed. — A receptacle for the solution — 
this may be of glass, agateware, or rubber. In 
domestic practice the two-quart rubber douche-bag 
or fountain-syringe is generally used (Fig. 20). 




Fig. 20. — Rubber douche-bag, tubing, 
and nozzle. 




Fig. 22. — Douche-pan. 



Fig. 2i. — Enamel- 
ware douche reservoir, 
rubber tubing with 
clamp, and glass vag- 
inal nozzle. 




Fig. 23. — Kelly 
pad. 



A piece of rubber tubing, four to six feet long and 
provided with a clamp, is attached to this recep- 
tacle. Vaginal nozzles of glass or hard rubber, 
curved or straight (Fig. 21). These must have 
openings at the sides and not at the tip, to prevent 
the entrance of fluid into the cavity of the uterus. 
Preparation for a Vaginal Douche. — Boil the 



DOUCHES 33 

nozzle in soda solution for five minutes, then 
place in a sterile pan until required. 

Mix the prescribed solution in a pitcher at the 
proper temperature. 

Place the patient in the dorsal position on a 
bed or table, with her hips resting upon a douche- 
pan (Fig. 22), Kelly pad (Fig. 23), or bed-pan, 
and properly covered with a sheet. A douche 
taken in the sitting posture is useless, because the 
fluid does not reach the upper part of the vagina. 

Method of Giving a Vaginal Douche. — Hang 
the douche-bag with its attached tubing from a 
nail or clothes-tree two feet above the level of 
the patient's hips, clamp the tubing, and fill the 
bag with the solution to be used at the proper 
temperature. After washing and disinfecting 
your hands, attach the nozzle to the tubing, 
being careful not to handle the end which is to 
be inserted into the vagina nor to let this come 
in contact with anything. Open the clamp 
and let the solution run through the tubing 
and nozzle until it comes warm; separate the labia 
with the thumb and forefinger of one hand; with 
the other hand carefully introduce the nozzle into 
the vagina for two or three inches; direct the tip 
toward the hollow of the sacrum and let the 
solution flow. 

There must be a good return flow from the 
vagina. To secure this it may be necessary to 
press the nozzle against one side of the vaginal 
orifice or posteriorly. After all the solution has 
run through, pinch the tubing; withdraw the 
nozzle and direct the patient to expel the fluid 
from the vagina by straining; then remove the 
douche-pan. 

In order to derive proper benefit the patient 
should remain in the recumbent posture for one 
hour after a hot douche. 

Boil the nozzle in soda solution for five minutes 



34 GYNECOLOGY FOR NURSES 

after using, and similarly disinfect the douche 
receptacle and tubing after an infectious case. 

Solutions Used. — Cleansing Douches. — Sterile 
water, normal salt solution, borax solution (tea- 
spoonful to quart) given at no° F. 

Disinfecting Douches. — Boric acid, teaspoonful 
to quart; potassium permanganate, i : 4000; 
bichlorid of mercury, 1 : 8000; creolin, teaspoonful 
to quart; lysol, teaspoonful to pint; carbolic acid, 
one teaspoonful in a tablespoonful of glycerin to 
the quart of water. Carbolic acid is insoluble in 
water and, unless mixed with glycerin, may float 
upon the surface of the douche and seriously burn 
the patient. Give at no° F. 

Depleting Douches. — Prolonged, hot vaginal 
douches, by reason of their secondary astringent 
action, produce depletion of all the pelvic organs. 
To obtain this effect a four- to eight-quart douche 
of sterile water or salt solution must be given 
every four hours, keeping the temperature of the 
solution at 110 to 115 F. throughout the flow. 

Emollient Douches. — Witch-hazel, one part to 
five of water. Give one quart at no° F. 

Astringent Douches. — Alum or zinc sulphate, 
one teaspoonful to the quart. 

To arrest hemorrhage, vaginal douches of salt 
solution or sterile water are given at 118 ° to 120 ° F. 

These hot solutions stimulate contraction of 
the uterus and of the blood-vessels. 

Intra -uterine Douches. — Intra-uterine douches 
are always given by the physician. They serve 
to remove debris from the cavity of the uterus, 
to disinfect the uterus, and to arrest hemorrhage 
from it. 

A disinfecting vaginal douche must precede 
every intra-uterine douche. 

Articles required: 

Kelly pad. 

Weight speculum. 



DOUCHES 



35 



Vaginal retractor. 

Tenaculum forceps. 

Douche-bag and tubing. 

Vaginal nozzle. 

Intra-uterine nozzle (Fig. 24). 

Preparation for an Intra-uterine Douche. — 
Sterilize the above-mentioned articles, with the 
exception of the Kelly pad, by boiling for ten 
minutes in soda solution. Lift the instruments 
into a sterile tray, cover with a sterile towel, and 
place on a table beside the bed. Pour hot sterile 
water over the instruments before using. 

Make ready for the physician hot water, nail- 
brush, soap, a basin of bichlorid solution, and a 
pair of sterile rubber gloves. 

Place the patient in the dorsal position upon a 
table or across the bed, with her hips drawn well 
over the edge and resting upon a Kelly pad. 



\ 



Fig. 24. — Intra-uterine nozzle. 



Wash the vulva with soap and water and disinfect 
with bichlorid solution. 

Hang the douche-bag eighteen inches above the 
level of the patient's hips, so that the solution 
cannot be forced through the uterine orifices into 
the Fallopian tubes. 

The douche-bag is first filled with the solution 



36 GYNECOLOGY FOR NURSES 

to be used for the disinfecting vaginal douche; 
after this has been given, with the solution or- 
dered for the intra-uterine douche. 

The simple, cleansing, intra-uterine douche is 
used most frequently during curettage, to wash 
away fragments of mucous membrane or placental 
tissue as they are loosened by the curet. Sterile 
water or salt solution is used at 115 F. 

Disinfecting intra-uterine douches are given 
after septic abortion or for septic endometritis. 
Alcohol and solutions of boric acid, lysol, or cre- 
olin are used. 

To arrest hemorrhage after curettage, abortion, 
or delivery at term, there is nothing better than the 
intra-uterine douche of salt solution or sterile 
water at 120 F. • 



GYNECOLOGIC DISEASES 

DISEASES OF THE VULVA 

Vulvitis is an inflammation of the vulva. 

Catarrhal vulvitis is caused by mechanical 
irritation, uncleanliness, irritating urine or dis- 
charges. The symptoms are burning pain, swell- 
ing, and increased secretion. 

Gonorrheal vulvitis results from infection by the 
gonococcus. The symptoms are similar to those 
of the catarrhal form, but more severe. The 




Fig. 25. — Abscess of the vulvovaginal gland in gonorrhea 
(Wilson). 

inflammation is prone to extend to the urethral 
mucous membrane, causing urethritis, with symp- 
toms of frequent and painful micturition. It mav 
also extend along the ducts of the vulvovaginal 
or Bartholin's glands, resulting in an abscess or 
suppurating cyst of one or the other gland. 

The symptoms of vulvovaginal abscess (Fig. 25), 
or abscess of the vulvovaginal gland, are acute 

37 



38 GYNECOLOGY FOR NURSES 

throbbing pain, swelling of one labium, mechan- 
ical interference with walking or standing. The 
treatment is surgical. 

If left to themselves, these abscesses open 
spontaneously in time; usually the opening is so 
small that drainage is imperfect and pus reaccumu- 
lates at intervals. The opposite gland becomes 
infected eventually, and the process drags out a 
weary length until the virulence of the germs is 
exhausted. 

Vulvovaginitis — a gonorrheal inflammation of the 
vulva and vagina may occur in female infants 
or little girls. This disease is caused by indirect 
infection through towels, diapers, thermometers, 
or the hands of attendants. It may be acute or 
chronic, and is frequently epidemic in babies' 
hospitals, orphans' homes, and similar institu- 
tions; only microscopic cleanliness will arrest its 
spread. 

Eczema Vulvce. — This is the commonest skin 
disease of the vulva. It results from uncleanliness, 
irritating discharges, diabetic or highly acid urine. 

Pruritus vulvce, itching of the vulva, is a symptom 
of eczema and vulvitis. 

Adhesions between the clitoris and the folds 
of mucous membrane covering it, or an accumula- 
tion of smegma in this location may give rise to 
severe local irritation and to marked reflex ner- 
vous disturbances. 

Urethral caruncle is the most frequent new- 
growth of the vulva. It is a small, bright-red 
growth, exquisitely sensitive, attached to the pos- 
terior margin of the meatus urinarius. These 
tiny growths cause great pain and deplorable 
nervousness. The treatment is surgical. 

Papillomata — warts — of the vulva are frequent. 

Fibromata (fibroid tumors) , lipomata (fatty 
tumors), carcinomata and sarcomata (malignant 
tumors), are rare. 



GYNECOLOGIC DISEASES 39 

Chancroid is an infectious ulcer of the vulva. 

Chancre, mucous patches, condylomata, and 
gummata are the various manifestations of syph- 
ilis occurring on the vulva. 

The nurse must be alert to detect suspicious 
lesions, and must guard against infecting herself 
or carrying infection to other patients by wearing 
rubber gloves when treating infectious cases, and 
by careful disinfection of hands, nozzles, ir^tru- 
ments, Kelly pads, and douche-pans between 
patients. 

LACERATIONS OF THE PERINEUM 

Perineal lacerations occur during child-birth 
and are classed as complete and incomplete. 
Complete lacerations are those extending through 
the sphincter ani; they are followed by loss of con- 
trol of this muscle and consequent incontinence of 
feces and gas. 

All lacerations predispose to descent of the 
vagina and uterus. 

DISEASES OF THE VAGINA 

Vaginitis is an inflammation of the vagina. 

Catarrhal vaginitis is caused by the mechanical 
irritation of pessaries or wool tampons. 

Infectious vaginitis is rare, owing to the pro- 
tective action of the lactic-acid bacillus. It is 
most apt to occur in children or in pregnant women, 
because of the greater delicacy of the mucous 
membrane in such patients. 

In old women a desquamative form of vaginitis 
is of frequent occurrence. This results in the 
formation of adhesions and more or less atresia 
of the vaginal canal. 

The symptoms of vaginitis are burning and 
increased secretion. The treatment consists in 
rest, douching, and local applications. 



40 GYNECOLOGY FOR NURSES 

Congenital atresia or obstruction of the vagina 
is usually discovered at puberty. 

The menstrual flow does not appear at the usual 
age; instead, there is a monthly recurrence of 
headache and lassitude, without any flow. Even- 
tually a fluctuating tumor appears above the 
symphysis, which consists of the vagina and 
uterus distended with menstrual blood. 

The cause of the obstruction is usually an 
imperforate hymen; in some cases there is an 
anomalous septum across the upper part of the 
vagina. 

The treatment of this condition is surgical, and 
consists in puncture or excision of the obstructing 
membrane. 

Vaginismus is a spasm of the muscles surround- 
ing the vaginal orifice; it interferes with examina- 
tion or treatment, and may be a cause of sterility. 

Most cases can be cured by gradual dilatation 
with glass vaginal dilators. 

Cysts and solid tumors of the vagina are rare. 

Cystocele is a downward displacement of the 
bladder and anterior vaginal wall. 

Rectocele is a downward displacement of the 
rectum and posterior vaginal wall. 

Cystocele and rectocele are caused by tears 
during child-birth and require operation for their 
cure. 

DISEASES OF THE UTERUS 

Injuries and Diseases of the Cervix. — Cer- 
vical lacerations occur during child-birth; they are 
described as lateral, bilateral, or stellate. They 
frequently lead to inflammation of the uterus, and 
are the commonest known cause of cancer of the 
cervix. 

These tears may be repaired immediately after 
delivery or at any time subsequently. They 
should always be repaired at the end of the child- 



GYNECOLOGIC DISEASES 41 

bearing period, because of the danger of malig- 
nant degeneration at this time. 

Endocervicitis is an inflammation of the cervical 
mucous membrane. It is frequently of gonorrheal 
origin; the chief symptom is leukorrhea. 

The treatment consists in local applications, 
Bier's hyperemia, cauterization, or curettage. 

Cervical polypi are benign growths derived from 
hypertrophy of the mucous membrane lining the 
cervix. They are usually pedunculated, and are 
prone to bleed upon touch. The treatment is 
surgical. 

Cancer of the cervix will be considered together 
with cancer of the body of the uterus. 

Diseases of the Body of the Uterus. — 
Endometritis is an inflammation of the mucous 
membrane lining the body of the uterus. It may 
be secondary to displacements of the uterus, or 
may be of infectious origin. 

Metritis is an inflammation of the whole sub- 
stance of the uterus. 

The symptoms of endometritis and metritis 
are increased discharge, profuse menstruation, 
pelvic pain, and tenderness. 

Displacements of the Uterus. — The normal 
position of the uterus is moderate anteversion. (See 
Fig. 6.) In anteflexion the body is bent forward 
sharply upon the cervix to form an angle. Un- 
developed uteri are usually anteflexed; the symp- 
toms of anteflexion are dysmenorrhea and ster- 
ility. 

In retroversion the whole organ is turned slightly 
toward the hollow of the sacrum. 

In retroflexion (Fig. 26) the body is bent back 
sharply on the cervix. 

The symptoms of backward displacements are 
backache, leukorrhea, dysmenorrhea, menorrha- 
gia, sterility, or repeated abortions. 

Prolapsus uteri is descent of the uterus below 



42 



GYNECOLOGY FOR NURSES 



its normal level in the pelvis. The causes of 
prolapse are falls, instrumental delivery, and 
perineal lacerations. In complete prolapse, or 
procidentia, the uterus appears outside of the 
vaginal orifice. 

Tumors of the Uterus. — The most common 
tumor of the uterus is a fibromyoma (Fig. 27), a 




Fig. 26. — Retroflexion of the uterus (Ashton). 



growth derived from hypertrophy of the normal 
fibrous and muscular tissue of the organ. 

These tumors may develop beneath the mucous 
membrane lining the uterus, and project into the 
uterine cavity, where they are called submucous 
fibromyomata. They may develop on the sur- 
face of the uterus, and grow toward the peritoneal 
cavity — subserous fibromyomata; or they may 
develop in the muscular wall of the uterus and 
produce a general enlargement of the organ without 
projecting nodules — interstitial fibromyomata. 

The symptoms of submucous fibromyomata are 
enlargement of the uterus, hemorrhage at or 
between the periods, leukorrhea, and dysmenor- 
rhea. Interstitial fibromyomata also cause hemor- 
rhage. The subperitoneal forms do not cause 



GYNECOLOGIC DISEASES 



43 



hemorrhage, but attract attention by increased 
size and pressure symptoms. 

The cause of fibroid tumors is unknown ; accord- 
ing to the latest theory, they are of congenital 
origin. They rarely produce symptoms before 
thirty years of age. Some of these tumors grow 
to a great size; they may complicate delivery, 
and usually delay the occurrence of the meno- 
pause; a small percentage undergo malignant 
degeneration. 




27. — Fibroid tumor of the uterus. 



The treatment is surgical. 

Cancer of the Uterus. — This is a malignant 
growth originating in the epithelium lining the 
cavity of the fundus or cervix as the case may be. 
Appearing first as a delicate finger-like out- 
growth, the disease progresses by infiltration, 
proliferation, and ulceration until the uterus is 
converted into a thin-walled sac, containing 
friable masses of broken-down tissue. Exten- 
sion of the disease into the broad ligaments con- 
verts the latter into densely infiltrated masses of 



44 GYNECOLOGY FOR NURSES 

almost stony hardness. In advanced cases the 
pelvic and abdominal lymphatic glands are en- 
larged. 

Cancerous growths of the uterus are classified 
according to their location and histologic struc- 
ture. The most frequent forms are the following: 

Squamous-celled carcinoma of the cervix. 

Adenocarcinoma of the cervix. 

Adenocarcinoma of the body. 

The two first-mentioned varieties are com- 
monly known as cauliflower growths of the cervix. 

The symptoms of this disease are bleeding, 
watery or purulent discharge, pain, emaciation, 
cachexia, anemia, and fever. Almost invariably 
the first symptom is bleeding, particularly irreg- 
ular bleeding, for example, between periods or 
after the menopause; bleeding following inter- 
course or straining at stool, after douching, or 
unusual exercise. The quantity of blood lost 
may be so slight that it appears only as a stain 
upon the clothing, but its significance cannot be 
overestimated. As the disease advances, bleed- 
ing becomes more profuse, and there may be a 
constant bloody discharge, with severe hemor- 
rhages from time to time. The other symptoms 
appear at a later and frequently inoperable stage 
of the disease. 

The treatment of cancer of the uterus is surgi- 
cal. When discovered early, an abdominal pan- 
hysterectomy is the operation of choice, while in 
inoperable cases of cervical cancer the use of the 
actual cautery may add some months of compara- 
tive comfort to the patient's life. 

From the standpoint of gynecology, cancer of 
the uterus is the most important medical subject 
of the day, and for the following reasons: 

(i) Its frequency. 

(2) Its increasing frequency. 

(3) Its curability by early operation. 



GYNECOLOGIC DISEASES 45 

Its Frequency. — Out of every ioo deaths among 
women, 1 2 are from cancer, and of these, 4 from 
cancer of the womb. In other words, more 
women die from cancer than from tuberculosis 
(100 as against 95 in 1905). Cancer of the womb 
attacks women of every age, married or single, 
white or black, but occurs most frequently in 
women of forty years and over who have borne 
children. Lacerations of the neck of the womb, 
such as occur in child-birth, predispose to the 
cancerous change. 

Its Increasing Frequency. — All over the world 
deaths from cancer are steadily increasing. 
While in 1859, 480 women died in England from 
cancer, in 1908, 1010 women died from this dis- 
ease. This increase is shown in graphic manner 
by the accompanying chart (Fig. 28). 

Without doubt this steady increase is due to 
the fact that the cause of cancer is unknown. 
When we know what it is that enters into the 
human body and produces this spreading loath- 
some growth, then we shall be in a position to 
destroy this cause and the death-rate from can- 
cer will begin to decline, just as the tuberculosis 
death-rate has declined since the discovery of the 
tubercle bacillus. Throughout the world phys- 
icians, scientists, and laymen are laboring to dis- 
cover this elusive cause; whoever finally succeeds 
will be one of the greatest benefactors of our race. 

Its Curability. — At present the one hopeful fact 
about cancer is this, at its beginning it is a purely 
local disease, and, if discovered and removed in 
this early stage, can positively be cured. The 
problem confronting the gynecologist today is, 
How can we reach women with cancer of the 
uterus in this early and curable stage? The 
answer to this question lies in a campaign of edu- 
cation which will reach every woman in every land, 
and establish our present-day knowledge of the 



46 



GYNECOLOGY FOR NURSES 



subject as a well-known household fact. No one 
is in a better position to serve in this crusade 
against cancer than an able and sympathetic 
nurse, who, while approaching this delicate sub- 
ject tactfully, can yet speak with the authority 
which commands attention. 

Summing up the facts contained in the pre- 




Fig. 28. — Table showing increase of cancer in England from re- 
port of Registrar General, 1908. 

ceding paragraphs, the following rules for the 
prevention of cancer may be laid down : 

Every woman who has a discharge of blood 
between periods should consult a physician. 

Every woman who flows excessively at the 
regular period should consult a physician. 

Every woman whose womb has been tornjn 



GYNECOLOGIC DISEASES 47 

childbirth or abortion should have these tears 
repaired before the age of forty-five. 

Every woman who wears a ring or pessary 
should have this removed every two months 
by a physician, who will detect ulceration if 
present. 

Every woman who has passed the menopause 
and who notices a bloody discharge, however 
slight, should be examined by a physician at 
once. 

If a case of cancer occurs in any household, it 
should be cared for as an infectious disease. All 
discharges should be collected on waste muslin. 
When removed, these should be wrapped in 
paper and promptly burned. Sheets and body 
linen should be disinfected with carbolic acid 
solution before entering the family wash. The 
patient should disinfect her hands after coming 
in contact with the discharge. The attendant 
should wxar wash gowns and aprons in the sick 
room, and rubber gloves while doing dressings; 
she should carefully disinfect her hands after 
touching the discharge and always before eating. 
When death comes, all clothing belonging to the 
patient should be burned, together with the mat- 
tress, carpet, and hangings of the room. Finally, 
the Board of Health should be called in to disin- 
fect the room or, better, the entire house. 

DISEASES OF THE FALLOPIAN TUBES 

Salpingitis is an inflammation of the Fallopian 
tube and may be catarrhal or purulent. 

Catarrhal salpingitis results from exposure to 
cold and wet, or may be secondary to displace- 
ments or fibroid tumors of the uterus. 

Purulent salpingitis results from infection by 
micro-organisms, for example, the gonococcus, 
streptococcus, or staphylococcus. It is usually 
secondary to a similar infection of the endome- 



48 GYNECOLOGY FOR NURSES 

trium. Tubercular salpingitis may be primary 
or secondary to tuberculosis of the peritoneum. 
These forms of inflammation lead to occlusion of 
the orifices of the tube, with the formation of a 
closed sac containing pus — a pyosalpinx. 

Hemorrhage into an occluded tube gives rise to 
a hematosalpinx, while hydrosalpinx is a tube dis- 
tended with serum; this is usually the sequel of a 
pyosalpinx after the germs have died and the pus 
has been converted into serum. 

Tubal Pregnancy. — Tubal pregnancy is one 
of the gravest gynecologic diseases. In this form 
of pregnancy the fertilized ovum does not reach 




Fig. 29. — Ruptured ectopic pregnancy. 

the cavity of the uterus, but lodges in some portion 
of the Fallopian tube and develops there. The 
growth of the ovum soon exceeds the stretching 
power of the tube, and it escapes by rupture of 
the tube (Fig. 29) or by abortion through the 
fimbriated extremity. 

The symptoms of rupture are agonizing pain 
in the corresponding ovarian region, syncope, 
feeble frequent pulse, subnormal temperature, 
and pinched features. These symptoms result 
from hemorrhage, shock, and mechanical injury. 

The patient may die from the first hemorrhage, 
but usually rallies and symptoms of rupture recur 
from time to time upon exertion or spontaneously. 



GYNECOLOGIC DISEASES 



49 



If left alone, the mortality is 70 per cent. The 
chief causes of death are hemorrhage and peri- 
tonitis. 

The treatment is surgical and consists in removal 
of the ovum and ruptured tube. While preparing 
for operation the symptoms of shock must be 
actively combatted. 

DISEASES OF THE OVARIES 

Oophoritis is an inflammation of the ovary. It 
may result from exposure to cold and wet and 
frequently attends chronic displacement of the 
uterus. 

The symptoms are pain and tenderness in the 
ovarian region, dysmenorrhea, sometimes excessive 
menstrual flow. 




Fig. 30. — Ovarian cyst. 



The treatment is palliative or surgical. The 
palliative treatment consists in rest, hot douches, 
and local applications of iodin and ichthyol. 

Solid tumors of the ovaries are rare. 

Ovarian cysts (Fig. 30) may result from the 
accumulation of fluid in a normal follicle — a follic- 
ular cyst; in the follicle after rupture — corpus 
luteum cyst; or may be a form of new-growth in 
which there is active proliferation of normal 



50 GYNECOLOGY FOR NURSES 

follicles with enormous increase in their size; 
these growths are termed proliferating glandular 
cysts or papillary cystadenomata if they contain 
solid masses also. 

Dermoid cysts are curious tumors, partly solid 
and partly cystic. They contain a heterogeneous 
collection of structures, such as hair, skin, teeth, 
bones, etc. 

The cause of these tumors is unknown; they 
are not peculiar to the ovary. 

The treatment of cysts and solid tumors of the 
ovary is surgical. 

PELVIC ABSCESS 

A pelvic abscess is a circumscribed collection 
of pus in the pelvis. It is caused by infection by 
the staphylococcus, streptococcus, bacillus coli 
communis, gonococcus, etc. 

The pus may be in the ovary — ovarian abscess; 
in the Fallopian tube — pyosalpinx; or the ovary 
and tube may together form the pus-sac — tubo- 
ovarian abscess. It may be in the pockets of the 
pelvic peritoneum, walled off from the general 
abdominal cavity by densely adherent intestines, 
or it may be in the cellular tissue between the 
folds of the broad ligaments or in front of or 
behind the uterus. 

The early symptoms of pelvic suppuration are 
those of an acute infection — localized pain and 
tenderness, high fever, rapid pulse, chills, sweats, 
prostration. These symptoms may last for days 
and weeks, and during this period the defenses 
of the body are at work, destroying germs, neu- 
tralizing poisons, and encapsulating the irritant 
by means of adhesive inflammation. 

When the inflammatory reaction is complete, 
the general symptoms subside and the patient is 
left emaciated and exhausted, with an encysted 
collection of pus somewhere in the pelvis. The 



GYNECOLOGIC DISEASES 5 1 

symptoms of the next stage are due to the pressure 
of this mass. 

In some cases the result is more tragic. The 
defenses of the body may prove inadequate, and 
death may result from general infection within a 
few days; or the pus, instead of becoming encysted 
and harmless, burro ws in one or another direction 
until it perforates some adjacent organ — bowel, 
bladder, or vagina. An intermittent discharge 
of pus characterizes this stage, w T hich, if long 
continued, results in death from exhaustion. 

The treatment of the first stage of suppurative 
pelvic inflammation consists in rest in bed in the 
Fowler position, ice to the abdomen, hot vaginal 
douches, supporting food, and medicine. Early 
operation is rarely called- for. Vaccine therapy 
may be helpful. 

After the inflammatory reaction has subsided, 
operation is indicated — vaginal incision and drain- 
age or the removal of pus-tubes by an abdominal 
operation. 



GYNECOLOGIC TREATMENT 

The non-surgical methods used in gynecology 
comprise — internal medication; the local applica- 
tion of drugs to the vulva, vagina, cervix, and 
endometrium; douches and sitz-baths; pessaries; 
the induction of hyperemia by the vacuum apparatus 
of Bier; electricity; pelvic massage, and the #-ray. 

Internal Medication. — The following drugs 
are used to arrest excessive bleeding from the 
uterus — ergot, hydrastis, stypticin, dilute sulphuric 
acid. 

Emmenagogues are drugs used to stimulate the 
menstrual flow; they include iron, manganese, 
apiol, and cantharides. 

Drugs used to replace normal secretions which 
are deficient or absent — ovarian extract, corpus 
luteum extract, thyroid extract, mammary extract. 

Drugs used for dysmenorrhea — viburnum 
prunifolium, phenacetin, diffusible stimulants. 

Local Applications. — Inflammatory lesions of 
the vulva and vagina are treated with the various 
lotions, powders, and ointments used for similar 
conditions of the skin and mucous surfaces else- 
where. 

Simple inflammatory lesions of the internal 
generative organs may be successfully treated by 
depleting tampons applied to the vaginal vault 
through a speculum. 

Acute backward and downward displacements 
of the uterus can often be cured by medicated 
tampons combined with postural treatment. The 
tampons are applied in the knee-chest position, 
and the patient is taught to assume this position 
52 



GYNECOLOGIC TREATMENT 



53 



several times a day for ten minutes at a time, and 
to sleep in the Sims position. The tampons 
remain in place one, two, or three days, depending 
upon the amount of discharge present; upon their 
removal, a cleansing vaginal douche is given. 
As a rule, a course of depleting douches is pre- 
scribed to alternate with the tampon treatments. 

The preparation for local treatment is the same 
as the preparation for gynecologic examinations, 
which has already been described on page 22. 

The drugs most frequently used are: 

Tincture of iodin. 

Argyrol in 25 per cent, and saturated solutions. 

Skene's solution (iodin and carbolic acid) . 




Fig. 31. — Pessaries: a Smith-Hodge; b, Gehrung; c, Menge's 
bar; d, ring. 



Silver nitrate solution, 10, 30, 60 grains to the 
ounce. 

Glycerite of ichthyol. 

Glycerite of iodin. • 

Glycerite of hydrastis. 

Boroglycerin. 

Keep the glycerites in ointment jars and pro- 
vide glass rods for spreading them upon the 
tampons. Provide blue poison bottles for the 
solutions. 

Pessaries. — Pessaries (Fig. 31) are used to sup- 
port the uterus and vagina. They are made of 
hard or soft rubber or of soft rubber inclosing 
a spiral spring. 



54 



GYNECOLOGY FOR NURSES 



After the correction of a movable retroversion 
a Hodge or Smith-Hodge pessary is inserted to 
maintain the uterus in the corrected position. 

The Gehrung pessary is used for cystocele. 
Ring pessaries are used for prolapse of the vagina, 
and the Menges bar pessary, with or without a 
handle, for procidentia. 

Pessaries are inserted by the physician; while 
they are being worn, a cleansing vaginal douche 
must be taken every night. The patient should 
visit the physician once a month, preferably after 
the menstrual period, for removal and replacement 
of the pessary. 




Fig. 32. — Hyperemia apparatus. 



Hyperemia. — The vacuum apparatus of Bier 
is a recent addition to the gynecologist's armamen- 
tarium. This apparatus consists of a cylindric 
glass tube, one end of which is open and fits over 
the cervix uteri; the opposite end is connected 
by rubber tubing with a suction pump (Fig. 32). 

By means of the suction pump the air in the 
glass tube is exhausted and a vacuum created which 
produces hyperemia of the cervix, and, at the 
same time, thoroughly evacuates the secretions of 
the cervical canal by suction. 



GYNECOLOGIC TREATMENT 55 

This form of treatment has proved particularly 
useful in chronic endocervicitis, gonorrheal or 
otherwise. 

Electricity. — Different applications of galvanic 
electricity are used to arrest excessive flow from 
the uterus and to stimulate undeveloped pelvic 
organs. 

X-ray. — The ^-ray is valuable in the treatment 
of skin disease of the vulva and malignant disease 
of the pelvic organs. 



MINOR GYNECOLOGIC OPERATIONS 

Preparation of the Patient for Minor Gyne- 
cologic Operations. — Give a mild laxative, a 
lapactic pill, or a teaspoonful of cascara mixture 
at eight o'clock of the night preceding the opera- 
tion. 

Give a cup of black coffee eight hours before 
the time set for operation, provided this hour 
does not come during the night. 

Send a specimen of the urine to the laboratory 
on the morning of the operation, and give a high 
soap-suds enema (see p. 138) six hours before 
the operation. If the bowels move more than 
twice after this, give a second enema of salt solu- 
tion. 

After the bowels are emptied, give a sponge-bath 
and an alcohol rub. Wash the lower abdomen, 
inner surface of the thighs, vulva, and perineal 
region as far back as the coccyx with soap and 
water and absorbent cotton. Wash from above 
downward, separate the labia carefully, and throw 
away the cotton after it has touched the anus. 
Shave the labia, rinse the parts with hot sterile 
water, and give a vaginal douche of bichlorid 
solution 1 : 8000. Wash the lower abdomen, 
inner surface of thighs, vulva, and perineum with 
the bichlorid solution, dry with a sterile towel, and 
apply a sterile vulvar pad fastened to a T-bandage. 

Dress the patient in an undervest, drawers, 
stockings, and short night-gown. Braid her hair 
in two braids. 

Shortly before the time set for the operation 
wheel a stretcher to the bedside and help the 
56 



PLATE I 




MINOR GYNECOLOGIC OPERATIONS 57 

patient upon it. Wrap her in a sheet and cover 
snugly with blankets; wheel the stretcher to the 
operating-room or etherizing-room, as the surgeon 
prefers. 

The Minor Operating Suite. — The minor 
operating suite consists of a dressing-room, scrub- 
bing-up room, etherizing-room, and operating- 
room. These rooms are in charge of a supervising 
nurse and an operating-room nurse. 

The Scrubbing-up Room. — This room contains 
an instrument sterilizer, a hot-water sterilizer, 
a washstand, and a long shelf for the solution 
basins. A basin of bichlorid solution holding a 
dipper and thermometer for mixing purposes 
is kept by the hot-water sterilizer. Two large 
enameled pails of cold sterile water and one pail 
of bichlorid solution 1 : 500 stand on the floor 
under the solution shelf. 

The minor operating-room (Plate I) is a small 
room, well lighted by a large window at one end. 
The floor is cemented; the walls are painted with 
white enamel. 

The furniture of the room consists of a glass 
operating table provided with detachable stirrup 
rods and an adjustable tray which receives all 
irrigating fluids and carries them into a waste- 
pan; a three-shelf glass instrument table; a glass 
instrument cabinet, three small enameled iron 
tables — one for the hypodermic outfit, one for 
dressings, and a third for the sterilizing and 
catheterizing outfit; a chair for the operator; 
a stool for the etherizer; a bench for solution pails; 
a stool for the operator's hand-basin; a stool for 
a basin of bichlorid solution; an enameled ware 
douche reservoir which hangs on the wall to the 
left of the operator; and an oxygen tank 

Care of the Rooms. — The rooms are swept and 
dusted daily; the furniture of the operating-room 
is wiped off with carbolic solution once a day, and 



58 GYNECOLOGY FOR NURSES 

the room is disinfected with formaldehyd gas 
after every infected case. 
Preparation of the Rooms for Operation. — 

Etherizing-room. — Lay out the etherizing outfit 
on a table in this room. 

Scrubbing-up Room. — Start the hot water ster- 
ilizer in good time. Lay out four sterile gowns 
in packages. Fill four hand-basins with hot 
water, and provide the same number of hand- 
brushes, nail-files, and jars of green-soap paste. 

Place three oval solution basins on the shelf, 
fill one with 70 per cent, alcohol; the second with 
a hot solution of bichlorid, 1 : 2000; the third 
with hot sterile water for hand disinfection. 

Operating-room. — The operating-table stands 
opposite the window and about four feet from it, 
with the stirrup end directed toward the window. 
Pad the table with a folded blanket and sheet, 
place a low pillow at the head end and a white 
enameled pail on the floor at the foot of the 
table. The stirrups are to be slipped in place 
after the patient is on the table. 

Place the etherizer's stool at the head of the 
table, and the operator's chair between the table 
and the window. 

Cover the various tables, benches, stools, and 
top of the instrument cabinet with clean towels. 

On the low bench place three covered buckets, 
two of cold sterile water and one of hot sterile 
water, and a basin of bichlorid solution 1 : 2000, 
containing a dipper and thermometer for mixing 
purposes. 

Place three glass jars containing iodoform 
gauze packing — narrow, medium, and wide — on 
a shelf over the instrument table. 

The small table for the catheterizing and dis- 
infecting outfit stands immediately under the 
enameled douche reservoir; the end of the rubber 
tubing from the reservoir lies coiled up in a basin 
of bichlorid solution upon this table. In addition, 



MINOR GYNECOLOGIC OPERATIONS 



59 



place upon this table a basin of bichlorid solution 
and one of sterile water; two pus pans — one for 
urine and one for uterine scrapings; a package of 
square gauze; a small tray holding a boiled glass 
catheter and vaginal nozzle; a bottle of green-soap 
mixture. 

Next to this table place a wooden stool holding 
a basin of bichlorid solution for the hands. 

The hypodermic table holds a box of hypodermic 
tablets, two sterile medicine glasses, two sterile 
hypodermic syringes, a bottle of alcohol, one of 
distilled water, one of camphor, one of whisky, 



n 

i 

i 


i 




II 


(1 


. <J 




Fig. 33- — i, Leglettes; 2, perineal curtain. 



one of adrenalin solution, 1 : 1000, vials of 
aseptic ergot, and a package of sterile square 
gauze. 

On the table for dressings place a package of 
sterile leglettes (Fig. 33, 1), a perineal curtain 
(Fig. 33, 2), a T-bandage, safety-pins, and a sterile 
vulvar pad. 

Spread a small sterile sheet over the top of the 
instrument table; lay out on the middle shelf three 
packages of sterile square gauze and a package 
of sterile towels; on the lowest shelf, a sterile 
basin for changing with the operator's hand-basin. 

Place a basin of sterile water on a stool to the 
right of the operator. 

Duties of Nurses at Operation. — When under 
ether the patient is wheeled into the operating- 



60 GYNECOLOGY FOR NURSES 

room and lifted upon the table, with her hips 
resting squarely upon the Kelly pad and extend- 
ing two inches over the edge of the table. Slip 
the stirrup rods into their sockets and arrange 
the patient in the lithotomy position, with thighs 
flexed upon the abdomen, legs upon the thighs, 
and feet in the stirrups. Pin her hands across 
her chest or above her head, and lay a folded 
blanket across her chest and abdomen. Push 
the patient's clothing well above her hips in the 
back and remove the vulvar pad. - 

The operating-room nurse, with sterile hands, 
washes the mons veneris, inner surfaces of the 
thighs, vulva, and perineum with green-soap 
mixture and sterile water. This done, she takes 
a pledget of cotton wet with green-soap mixture 
in one hand and in the other an irrigating nozzle 
connected with the douche-can filled with hot 
sterile water. She holds the ball of cotton in the 
vagina and, under a constant stream of water, 
smoothes out all the folds of the vagina and scrubs 
it thoroughly from the cervix to the vulvar orifice, 
removing all discharges and debris. When the 
hymen is intact, this procedure must be carried 
out with the utmost gentleness; in order to avoid 
tearing the delicate membrane, small pledgets of 
cotton must be used, held in the grasp of sponge- 
forceps. After the soap-and-water cleansing the 
vulva and vagina are irrigated with bichlorid 
solution i : 8000, followed by sterile water. 

After the final sterilization the operating-room 
nurse catheterizes the patient and fastens the 
perineal curtain in place, tying it around the 
patient's legs on each side. The package of 
sterile leglettes is opened and handed to the as- 
sistant, who slips them over the patient's legs 
and stirrup rods and spreads a sterile towel over 
the lower abdomen, and over the tray of the 
operating-table. 



MINOR GYNECOLOGIC OPERATIONS 6 1 

The operating-room nurse watches the opera- 
tor's hand-basin and removes it if the water be- 
comes bloody, immediately replacing it by a 
basin of fresh sterile water. 

When irrigation is called for, she lifts the coil 
of rubber tubing out of the bichlorid basin and 
hands it, without touching it near the free end, 
to the instrument passer, who slips the vaginal 
nozzle or irrigating curet into the tubing and 
hands it to the operator, resting the tubing upon 
the operator's right shoulder. 

If it is desired to save specimens from curettage, 
this nurse holds the pus pan with its convex curve 
toward the table, a few inches below the weight 
speculum. These specimens, properly labeled, 
must be sent to the laboratory immediately after 
the operation. 

The supervising nurse selects and sterilizes the 
instruments and suture material for each operation. 
The instruments are lifted from the sterilizer into 
sterile instrument trays, which are placed on the 
top shelf of the instrument table. After the 
operation she washes the instruments, sterilizes 
them, and puts them away in the instrument 
cabinet. 

During the operation she administers hypoder- 
mics, if required; waits upon the etherizer, and 
directs the duties of the operating-room nurse. 

When the operation is finished, one nurse lifts 
the patient's hips; the other removes the soiled 
towels and wipes the buttocks clean and dry. The 
vulvar pad is applied and pinned to a T-bandage 
fastened around the patient's waist. The stirrup 
rods are removed, the stretcher is rolled in, and 
the patient is lifted upon it, wrapped snugly in 
blankets, and returned to her bed. 

The operating-room nurse proceeds to put the 
room in order. 



62 



GYNECOLOGY FOR NURSES 



DESCRIPTION OF MINOR GYNECOLOGIC OPERA- 
TIONS 

Removal of a Urethral Caruncle. — This 
slight operation may be performed under general 
anesthesia or under local anesthesia with cocain; 
if the latter, no preliminary preparation is re- 
quired aside from cleansing and disinfection of 
the vulva. 

The preparation on the table is the same as for 




Fig. 34. — Instruments for excision of a urethral caruncle: 
1, Urethral dilator; 2, anatomic forceps; 3, straight scissors; 
4, curved scissors; 5, needle-holder; 6, needles; 7, hemostats; 
8, catheter. 



the minor operations, except that it is not necessary 
to disinfect the vagina. The caruncle must be 
touched very gently, because it is exquisitely 
sensitive. 

If cocain anesthesia is to be used, the nurse 
injects a 10 per cent, solution of the drug into the 
urethra by means of an eye-dropper, and places 
a cotton ball saturated in the same solution against 
the caruncle. This anesthesia is complete in 
three minutes and lasts about ten minutes. 

Steps in the Operation— The urethral orifice 
is dilated, the caruncle drawn down, and sutures 
passed under it; it is excised and the sutures tied. 



MINOR GYNECOLOGIC OPERATIONS 63 

Instruments (Fig. 34): 

Urethral dilator. 

Anatomic forceps. 

Needle-holder. 

Fine needles, short and full curved. 

One pair sharp-pointed scissors, straight. 

One pair sharp-pointed scissors, curved. 

Six hemostats. 

Catheter. 

Supplies. — Square gauze, fine silk, chromicized 
catgut No. 1. 

Dressings. — After the operation a thick compress 
of square gauze is pressed against the urethral 
orifice and held in place by a sterile pad and 
T-bandages. 

Ajter-care. — Catheterize every eight hours if re- 
quired. Irrigate with bichlorid solution 1 : 10,000. 
after urination and defecation. Keep the patient 
in bed five days. 

Evacuation of a Vulvovaginal Abscess. — 
This operation is usually performed under local 
anesthesia by freezing with ethyl chlorid. 

The preparation on the table is the same as for 
other minor operations. 

Steps in the Operation. — The skin overlying the 
abscess is frozen, and the wall of the abscess is 
freely incised. The cavity may be irrigated with 
sterile salt solution or swabbed with carbolic 
acid; it is always packed. 

Instruments : 

Knife. 

Scissors. 

Probe. 

Tissue forceps. 

Six hemostats. One spoon curet. 

Supplies. — Square gauze and narrow folded 
iodoform gauze packing. 

The dressings and after-care are the same as 
for the preceding operation. The abscess cavity 
is repacked daily until healed. 



64 



GYNECOLOGY FOR NURSES 



Excision of a Vulvovaginal Cyst. — The routine 

preparation is followed. 

Steps in the Operation. — An incision is made 
over the cyst, which is dissected out from its 
connective-tissue bed; bleeding arteries are tied 
and the space closed by buried and superficial 
sutures of catgut. 

Instruments (Fig. 35): 

Knife. t 

Blunt dissector. 

Twelve hemostats. 

Scissors, curved and straight. 

Fine, full-curved needles. 

Needle-holder. 




Fig- 35- — Instruments for excision of a vulvovaginal 
cyst: 1, Straight scissors; 2, curved scissors; 3, knife; 4, needle- 
holder; 5, hemostats; 6, blunt dissector. 



Supplies. — Square gauze. No. 1 catgut, plain 
and chromicized. 

The dressings and after-care are as above 
described. 

Dilatation and Curettage. — This operation 
consists of two parts: first, stretching the cervix 
and orifices of the uterus; second, scraping away, 
by means of a curet, the lining mucous membrane, 
together with any debris or products of conception 
that may be contained in the cavity. 

The routine preparation is followed, except 
that the labia are not shaved. 

Steps in the Operation. — The cervix is exposed 
and seized with a tenaculum forceps, the orifices 



MINOR GYNECOLOGIC OPERATIONS 



65 



and cervical canal are dilated, the mucous mem- 
brane and debris are scraped away, the cavity is 
irrigated, wiped dry, and packed or drained with 
folded gauze. 

Instruments (Fig. 36) : 

Weight speculum. 

Vaginal retractor. 

Tenaculum forceps. 

Uterine sound.' 

Small and large Goodell dilators. 

Curets — dull, sharp, triangular, fundus. 

Packing forceps. 

Scissors. 

Sponge-forceps. 

Glassware: 

Catheter. 

Vaginal nozzle. 

Intra-uterine nozzle. 




Fig. 36. — Instruments for dilatation and curettage: 
1, Fundus forceps; 2, weight speculum; 3, vaginal retractor; 4, 
tenaculum forceps; 5, uterine sound; 6, 7, large and small 
Goodell dilator; 8, dull curet; 9, sharp curet; 10, triangular 
curet; 11, packing forceps; 12, scissors; 13, sponge-forceps. 

Dressings. — T-bandage and sterile vulvar pad. 

After-care. — After the temperature reaches 99 ° F., 
apply an ice-bag to the hypogastrium. If packing 
has been used, it will be removed by the physician 
twenty-four hours after operation. Prepare for 
the physician a nail-brush and soap, hot water, 
and bichlorid solution. Disinfect the vulva, 



66 



GYNECOLOGY FOR NURSES 



arrange the patient in the dorsal position length- 
wise of the bed. Provide a pair of sterile dressing 
forceps and a pus pan. 

After removal of the packing, give a vaginal 
douche of bichlorid solution, and daily thereafter 
a boric-acid douche. 

The bowels are moved after one to three days, 
and the patient remains in bed one week or 
longer. 

Diet. — Commence liquid diet after the stomach 
is settled, and continue it for twenty-four hours. 
Give semiliquid diet on the second day and solid 
food on the third. 

Give water freely throughout the convalescence. 

Trachelorrhaphy. — Trachelorrhaphy is the re- 
pair of a lacerated cervix. 




Fig. 37 — Instruments for trachelorrhaphy: 1, Weight 
speculum; 2, vaginal retractor; 3, tenaculum forceps; 4, tissue 
forceps; 5, uterine sound; 6, knife; 7, curved scissors; 8, needle- 
holder; 9, needles. 



The routine preparation is followed. 

Steps in the Operation. — The cervix is exposed, 
the area to be denuded is outlined, the scar tissue 
is excised, and the denuded surfaces are approxi- 
mated by sutures. 

Instruments (Fig. 37): 

Weight speculum. 

Vaginal retractor. 

Two tenaculum forceps. 



MINOR GYNECOLOGIC OPERATIONS 67 

Uterine sound. 

Knife. 

Tissue forceps with teeth. 

Curved sharp-pointed scissors. 

Needle-holder. 

Cervical needles — short, full-curved, cutting 
edge. 

Suture Materials. — Plain catgut No. 1., chro- 
micized catgut No. 11., and silkworm-gut. 

The after-care is the same as for dilatation and 
curettage, with the exception of douches, which 
are not given unless especially ordered. 

When silkworm-gut sutures are used, they are 
removed on the fourteenth day. 

For their removal place the patient in the dorsal 
position cross-bed, or preferably upon an examining 
table in a good light. Provide an electric drop 
light when possible. 

The physician sits on a stool in front of the 
patient and requires the following instruments: 

Weight or Sims speculum. 

Vaginal retractor. 

Single tenaculum. 

Long, sharp-pointed scissors. 

Long anatomic forceps. 

Give a bichlorid douche after the stitches are 
removed. 

Amputation of the Cervix.— This operation 
consists in the removal of the hypertrophied or 
badly lacerated cervix. 

Steps in the Operation. — The cervix is exposed, 
the hypertrophied areas are outlined and excised, 
the cut surfaces are approximated by sutures. 

The preparation, instruments, supplies, and 
after-care are the same as for trachelorrhaphy. 

Colporrhaphy. — Colporrhaphy is the repair 
of a tear of the vagina. 

The routine preparation. is followed. 

Steps in the Operation. — The area to be denuded 



68 



GYNECOLOGY FOR NURSES 



is outlined, the mucous membrane is cut away, 
and the sutures are introduced and tied. 

Instruments (Fig. 38): 

Weight speculum. 

Two tenaculum forceps. 

Knife. 

Twelve hemostats. 

One pair straight scissors. 

One pair curved, sharp-pointed scissors. 

Anatomic forceps. 

Needle-holder. 

Martin needles No. 3. 

Suture material: 

Plain catgut No. 1. 

Chromicized catgut No. 1. and 11. 




Fig. 38. — Instruments for colporrhaphy : i, Weight 
speculum; 2, tenaculum forceps; 3, anatomic forceps; 4, 
knife; 5, hemostats; 6, needle-holder; 7, straight scissors; 
8, curved scissors; 9, needles. 



After-care. — Catheterize every four hours, other- 
wise follow the routine for trachelorrhaphy. 

Cystocele Operation. — This operation is prac- 
tically an anterior colporrhaphy with replace- 
ment of the prolapsed bladder. 

The routine preparation is followed. 

Steps in the Operation. — A straight incision is 
made in the median line of the anterior vaginal 
wall over the prominent cystocele, flaps are sepa- 



MINOR GYNECOLOGIC OPERATIONS 



6 9 



rated on each side by blunt and sharp dissection, 
and the bladder is pushed up beyond the level of 
the internal os. The fascial planes of the 
anterior vaginal wall are approximated by buried 
sutures of catgut, after which the mucous mem- 
brane flaps are united by interrupted catgut 
sutures after suitable trimming off. 

Instruments. — The same as for colporrhaphy, 
with the addition of a bladder sound. Suture 
material and after-care the same. 

Perineorrhaphy is the repair of a torn peri- 
neum. 




Fig. 39.— Instruments for perineorrhaphy: 1, Tenaculum for- 
ceps; 2, knife; 3, anatomic forceps; 4, straight scissors; 5, curved 
scissors; 6, hemostats; 7, needle-holder; 8, shot compressor; 9, 
needles. 

The routine preparation is followed. 

Steps in the Operation. — The area to be denuded 
is outlined, denuded, and approximated by 
sutures. 

Instruments (Fig. 39) : 

One large and two small tenaculum forceps. 

Knife. 

Anatomic forceps. 

One pair straight scissors. 

One pair curved, sharp-pointed scissors. 

Twelve hemostats. 

Needle-holder. 

Martin's needles Nos. 2 and 4. 



70 GYNECOLOGY FOR NURSES 

Perforated shot. 

Shot compressor. 

Suture material: 

Plain catgut No. i. 

Chromicized catgut Nos. i. and 2. 

Silkworm-gut. 

After-care. — Catheterize the patient every 
eight hours if she is unable to urinate. 

The bowels are locked for forty-eight hours, 
and during this time alternate feedings of beef- 
juice and albumin-water are given. On the third 
day a capsule is given containing three grains of 
calomel and a half-grain of podophyllin; four 
hours later give a low soap-suds enema through 
a small, soft-rubber rectal tube. 

After the bowels move give semiliquid diet until 
the seventh day; then full tray and feedings at 
10, 3, and 8 o'clock. 

Care of the Stitches. — The success of a perineal 
operation depends largely upon the nurse who 
cares for the stitches; the secret of success lies 
in keeping them clean and dry without pulling 
upon them. 

Direct the patient to keep her knees together 
as much as possible. She may be turned from side 
to side with assistance, the nurse lifting the buttocks 
while the patient holds her knees firmly together. 

Dress the stitches after urination and defecation 
or three times a day, if the patient is being cathe- 
terized. First carefully scrub and disinfect your 
hands, then irrigate the stitches with a gentle 
stream of sterile water at 105 ° F., using a douche- 
bag and irrigating nozzle or an irrigating pitcher. 

After irrigation, dry the stitches carefully with 
squares of sterile gauze, separating the patient's 
knees as little as possible. The dressing consists 
of several layers of square gauze laid against the 
perineum and held in place by a sterile pad fast- 
ened by a T-bandage. 



MINOR GYNECOLOGIC OPERATIONS 7 1 

Report daily the condition of perineal stitches, 
noting the character and amount of discharge, 
the presence of blood, or cutting of the 
stitches. 

Douches. — Vaginal douching plays no part in 
the routine after-care of perineorrhaphies, but 
occasionally some other minor operation is per- 
formed at the same time which necessitates a daily 
vaginal douche. ' 

In giving this, great care must be exercised to 
avoid injury to the recently repaired perineum. 
The ordinary glass vaginal nozzle is entirely too 
large; instead of this, a slender glass catheter 
should be used. The nurse must have a good 
light, so that she can see exactly where the vaginal 
orifice is, and must bear in mind that, immediately 
after a perineorrhaphy, this orifice is very much 
narrowed and may be smaller than in the virgin. 
Remember that the orifice lies above all the stitches; 
insert the catheter carefully, and allow it to take 
whatever direction it will. 

Perineorrhaphies have often been ruined by 
using too large a nozzle or by pushing the nozzle 
between the stitches into the newly made perineum. 
If the patient complains of pain, or if any obstruc- 
tion is encountered, it is proof that the catheter is 
being inserted in a wrong direction. 

Silkworm-gut stitches on the perineal body are 
removed on the seventh day; those within the 
vagina, on the fourteenth day. For their 
removal, place the patient in the dorsal position 
across the bed or, preferably, on a table facing a 
good light. 

Provide for the surgeon a brush, soap, and hot 
water, a basin of bichlorid solution, and a stool. 

The following instruments may be required 
and should be in readiness: 

Small Sims speculum. 

Long and short sharp-pointed scissors. 



72 GYNECOLOGY FOR NURSES 

Long and short anatomic forceps. 

Single tenaculum. 

After the first stitches are removed, the patient 
receives full diet; and after the last stitches are 
removed, she may get out of bed; on the twenty- 
first day she may leave the hospital, but should 
avoid all efforts at lifting or straining for a few 
weeks longer. 

The marital relation may be resumed after six 
weeks. 

Care After Operation for Complete Perineal 
Tear. — In these cases the bowels are locked for 
a week, the diet being restricted to beef-juice and 
albumin water. 

On the eighth day calomel and podophyllin are 
given in capsule, followed after four hours by a 
wineglassful of Hunyadi water, to be repeated 
every two hours. An oil enema is given with the 
first dose of Hunyadi water and is retained. When 
the patient feels an inclination for a movement, 
a soap and water enema is given. 

Vaginal Evacuation of a Pelvic Abscess. — 
The routine preparation is followed. 

Steps in the Operation. — The vaginal vault is 
exposed and incised over the abscess; the abscess 
is opened, its cavity flushed and packed. 

Instruments (Fig. 40): 

Weight speculum. 

Vaginal retractors. 

Tenaculum forceps. 

Knife. 

Long scissors, straight and curved. 

Two sizes of Goodell dilators for enlarging the 
opening. 

Long, slender packing forceps, curved and 
straight. 

Short, straight scissors. 

Have ready for irrigation a douche-bag and 



MINOR GYNECOLOGIC OPERATIONS 



73 



tubing, intra-uterine nozzle, two-way catheter, 
salt solution or boric-acid solution. 




Fig. 40.- — Instruments required for vaginal evacuation 
of a pelvic abscess: 1, Weight speculum; 2, vaginal retractor; 
3, tenaculum forceps; 4, knife; 5, long scissors, straight and 
curved; 6, short straight scissors; 7, Goodell dilators; 8, long, 
slender packing forceps. 

Provide rubber drainage-tubing, J and J inch 
wide, and folded iodoform gauze packing. 

The after-care is the same as for dilatation and 
curettage. Douches may or may not be ordered; 
the patient stays in bed several weeks. 

The abscess cavity is repacked, and possibly 
irrigated, every twenty-four to forty-eight hours, 
or at longer intervals until healed. For these 
dressings place the patient in the dorsal position 
across the bed, facing a good light, and with her 
hips on a Kelly pad. 

Disinfect the vulva before the packing is removed; 
after it is removed give a bichlorid vaginal douche. 

Instruments: 

Weight speculum. 

Vaginal retractors. 

Two tenaculum forceps. 

Two dressing forceps. 

Small Goodell dilator. 

Two-way catheter. 



74 GYNECOLOGY FOR NURSES 

MINOR OPERATIONS IN PRIVATE HOUSES 

The nurse should arrive at least one day pre- 
ceding the operation. Select for the operation a 
well-lighted room — either the patient's bed-room 
or another room on the same floor. 

Remove unnecessary furniture, heavy hangings, 
small pictures, and bric-a-brac. Fresh wash cur- 
tains may remain. Have the room thoroughly 
swept the day before operation, and the furniture 
wiped off with a damp chamois. Where the floor 
is covered with rugs which can be taken up easily, 
have this done; if not, protect the carpet with 
oil-cloth or thick layers of newspaper covered 
with a carbolized sheet. 

The surgeon may send a portable operating- 
table to the house; otherwise a firm kitchen table 
is a good substitute. Let the table be scrubbed 
downstairs with hot water and soap, carried 
upstairs on the day of operation, and placed before 
the window. 

Pad the table with a blanket and sheet, place 
a small pillow at the head end, the Kelly pad at 
the opposite end, a pail on the floor under the 
apron of the Kelly pad, a chair for the operator 
between the table and the window, and a small 
table to the right of this chair, for the operator's 
hand-basin of sterile water. 

Use the top of the bureau for sterile supplies 
and for the scrubbing-up and catheterizing outfit. 

Provide a table for the instrument passer; hang 
the patient's douche-bag on a stout nail or clothes- 
tree, about two feet above the level of the operating 
table. 

Arrange one bed-room as a doctor's dressing- 
room. Provide hand-basins, brushes, and jars 
of soap paste for the operator and assistants; 
these may be arranged in the bath-room, in a 
bed-room, or in the operating-room. 

Use the washstand in the operating-room for 
disinfecting solutions — one basin of bichlorid 



MINOR GYNECOLOGIC OPERATIONS 



75 



solution and one of alcohol are sufficient. Place 
the basin of rubber gloves here also. 

On the night before operation fill a clean wash- 
boiler with water, boil for one hour, and set aside 
to cool. 

On the morning of operation sterilize the 
various basins, pitchers, and douche bag by 
boiling for twenty minutes in the wash-boiler. 
Eight basins will probably be required. Car- 
bolize the Kelly pad in the bath-tub. When the 
time set for the operation approaches be sure 
that the wash-boiler filled with water is kept 
boiling on the range. 




Fig. 41. — Leg-holder. 

The preparation of the patient is the same as 
in the hospital. She is usually etherized on the 
table. The one nurse in attendance does not 
sterilize her hands; she arranges the patient in 
position, and waits on the etherizer. 

After the patient is under ether the nurse ad- 
justs the stirrup-holder, or whatever form of leg- 
holder (Fig. 41) has been provided. If leg-holders 
are used, bear in mind that the body strap should 
pass over one shoulder and under the other. 

Cleansing and disinfection of the patient on the 
table is carried out by one of the assistants. 



76 GYNECOLOGY FOR NURSES 

Boil the instruments in an instrument boiler 
or clean fish-kettle. The same vessel serves as an 
instrument tray after pouring off the hot water and 
covering the instruments with cool sterile water. 

Wrap the gloves in a towel and boil in a basin. 

Obtain packages of sterile supplies — towels, 
gowns, gauze, leglettes, etc., from the hospital 
with which the surgeon is connected. 

In emergency operations in private houses, much 
of this preparation must be dispensed with. The 
first thing to plan for is the supply of cold boiled 
water, and the first step in the preparation is to 
put a kettle of water on to boil for this purpose, or 
distilled water may be purchased from the drug 
store. As a rule, there is plenty of hot sterile 
water, but there may be great need of cold. 

Disturb the room as little as possible, so as to 
avoid raising dust. Cover, with clean towels, the 
various pieces of furniture needed for the opera- 
tion; provide two basins — one for scrubbing up, 
the other for bichlorid solution. 

Boil the instruments in a fish-kettle or dish-pan 
which does duty as an instrument tray also. 

Lift the patient out of bed upon a padded kitchen- 
table. A Kelly pad may be improvised by using 
a heavy bath-towel rolled lengthwise and curved 
to form the hollow of the Kelly pad; place over this 
a piece of oil-cloth pinned together in front to simu- 
late the apron of the Kelly pad. 

As a substitute for a leg-holder a sheet twisted 
into a rope may be used. Two people take hold of 
diagonal corners of the sheet and twist in opposite 
directions until a rope is formed. Place the center 
of the twisted sheet under the patient's neck; pass 
one end under one shoulder, the other end over 
the opposite shoulder. After the patient is ether- 
ized, flex the thighs on the abdomen and tie each 
end of the sheet around the corresponding thigh 
above the knee. 



^ 



MAJOR GYNECOLOGIC OPERATIONS 

Preparation of the Patient. — In emergency 
cases a thorough disinfection, on the table, of the 
skin of the abdomen may be the only preparation 
possible, but in all other cases a careful examina- 
tion of the mouth, lungs, heart, blood-vessels, 
blood, and urine should precede operation. If 
the twenty-four-hour quantity of urine falls below 
30 ounces, if granular casts are found, or glyco- 
suria, if the hemoglobin percentage is below 50, 
the blood-pressure above 150, the chest full of 
rales, the mouth offensive from decayed teeth, 
etc., the patient is a poor surgical risk, and 
preparatory treatment extending over days or 
weeks may be required. If the nature of the 
surgical lesion renders such delay impossible, 
additional precautions must be taken to minimize 
the dangers of shock, hemorrhage, and anesthesia. 
After the patient has been passed upon favorably 
by the medical and laboratory examiners, and the 
date and hour for operation has been set, the im- 
mediate preparatory treatment for which the 
nurse is directly responsible can be begun. Its 
object is threefold: To secure a thorough empty- 
ing of the intestinal tract, to disinfect the skin in 
the region of the incision, and to stimulate the 
excretory function of the skin and kidneys. 

The Day Before Operation. — The patient usu- 
ally enters the hospital the day before operation; 
she should be advised to drink water freely and 
is given a light supper. After supper she is given 
a warm sponge or tub-bath and the abdomen is 
prepared. The nurse first scrubs her hands and 

77 



V 



78 GYNECOLOGY FOR NURSES 

forearms for ten minutes with hot water and soap, 
and then immerses them for two minutes in alco- 
hol or bichlorid solution (i : 8000). The whole 
abdominal wall from the costal border to the 
symphysis and from flank to flank, the groins and 
upper part of the thighs, must be thoroughly 
scrubbed for ten minutes with sterile gauze, hot 
sterile water, and tincture of green soap, paying 
special attention to the umbilicus and pubic 
region. Shave the abdomen and mons veneris 
with a sterile razor, wash the surface with sterile 
water, followed by 70 per cent, alcohol, dry with 
sterile gauze, and apply a sterile gauze dressing 
and binder. At 9 p. m. give 1 to 2 ounces of 
castor oil; give nothing by mouth after midnight. 

Day of Operation. — At 5 a. m. or later, depend- 
ing upon the time set for operation, give a high 
soapsuds enema, followed by a douche of bi- 
chlorid solution, 1 : 8000. Send a specimen of 
urine to the laboratory. Two hours before opera- 
tion remove the abdominal dressing and paint the 
skin of the abdomen from "costal border to sym- 
physis and flank to flank" with tincture of 
iodin, 5 per cent. Apply a fresh dressing of 
sterile gauze and a sterile straight binder. As 
the time for operation approaches dress the 
patient in sterile clothes, wrap in a sterile sheet, 
lift her upon the stretcher, and wheel to the 
operating-room. 

The Major Operating Suite. — The major 
operating suite comprises the following rooms: 
operating-room, etheri zing-room, sterili zing-room, 
supply-room, doctor's dressing-room, scrubbing- 
room, and bath-room. These rooms are situated 
on the top floor of the hospital, away from the noise 
and dust of the street. 

The major operating-room is a large room, thirty 
feet long by twenty feet wide and twelve feet high. 
It is well lighted by two large windows facing the 






FLATE II 




MAJOR GYNECOLOGIC OPERATIONS 79 

north, and by a skylight. The floor is covered 
with white metile, the walls with white glazed 
tile to a height of four feet; the walls above this 
and the ceiling are painted with white enamel 
paint. A door at one end of the room opens into 
the hall; one at the opposite end opens into the 
scrubbing-room. (See Plate II.) 

The room is heated by two steam radiators 
placed under the windows, and is lighted by elec- 
tricity: a four-branched electrolier is suspended 
under the skylight, three feet above the operating 
table. 

Two marble shelves are fastened to the wall at 
one end of the room. 

Furniture of the operating-room: 

1 Boldt operating table. 

1 glass instrument case. 

2 footstools for the surgeons. 

1 revolving stool for the etherizer. 

1 two-shelf instrument table. 

5 small two-shelf tables: one for the scrubbing 
outfit, one for sponges, one for salt solution, one 
for the hypodermic outfit, and one for the hypoder- 
moclysis outfit. 

1 stool for the operator's hand-basin. 

1 double basin rack. 

3 benches. 

1 enameled chair. 

1 irrigating stand., 

1 oxygen tank. 

Care of the Operating-room. — The room is 
cleaned daily by the ward-maid; once in twc 
weeks it is disinfected for twenty-four hours 
with formaldehyd gas; this is repeated after 
every septic operation. The windows are 
kept tightly closed, except while the room is 
being cleaned. 

The ether izing-r 00m contains a stool for the 
etherizer, a table for the etherizer's outfit, a table 



80 GYNECOLOGY FOR NURSES 

for the hypodermic outfit, a table for the catheter - 
izing outfit, a tank of oxygen, and a nitrous oxid 
gas apparatus. 

The sterilizing-roorn contains a large table for 
the preparation of supplies, two high stools for 
the nurses, one filter, one hot and cold water 
sterilizer, one instrument boiler, one steam steril- 
izer, one dry sterilizer, and one utensil sterilizer. 

The scrubbing-room contains a three-bowled 
stationary washstand provided with foot-taps, a 
shelf for the basins of disinfecting solutions, and a 
stand for the basin of sterile gloves. 

The doctor's dressing-room contains a wardrobe 
for the surgeon's street clothes, a bureau in which 
the operating suits are kept, chairs, table, and a 
bed. 

The supply-room contains closets with abundant 
shelf and drawer space for storing supplies, suture 
material, etc. 

Circular muslin capes for visitors are kept in 
a closet in this room. 

Staff of Nurses. — Four nurses are on duty 
in the major operating suite: the instrument 
nurse, the surgical supervisor, the operating- 
room nurse, and the sponge nurse. The two 
latter are pupil nurses; each serves for six weeks 
under the direction of the surgical supervisor, 
who is a graduate nurse holding a permanent 
position in charge of the major operating floor. 

Duties of the Operating-room Nurse. — The 
operating-room nurse is responsible for the order 
and cleanliness of the entire operating suite. She 
daily tests the electric lights in each room, and 
keeps the rooms at a temperature of 75 ° to 8o° F. 
Under the direction of the surgical supervisor she 
prepares and sterilizes all the salt solution used 
throughout the hospital, and all dressings and 
supplies used on the major operating floor. Sup- 
plies for the rest of the hospital are prepared on 



MAJOR GYNECOLOGIC OPERATIONS 8l 

the different floors, and are sent to the major 
operating floor for sterilization. 

On operating days, she prepares the various 
rooms of the operating suite, lays out supplies, 
assists in the operating-room, and puts the rooms 
in order after the operations are over. 

Duties of the Surgical Supervisor. — The surgical 
supervisor is responsible for the surgical cleanliness 
of the operating suite and for the technic of the 
nurses under her. 

She superintends the operating-room nurse in 
the preparation of salt solution, supplies, and 
operating suite. 

She selects and sterilizes the instruments, suture 
material, and gloves used at each operation; and, 
after operation, cleans the instruments and puts 
them away. 

The Preparation of Salt Solution.— Sterile 
salt solution is used for flushing the abdom- 
inal cavity, for hypodermoclysis, and for intra- 
venous injection. It is prepared and stored 
in glass Erlenmeyer flasks, each holding i or 2 
quarts. 

Before using, the flasks are washed with 
hot water, green-soap mixture, and ammonia, 
rinsed in sterile w^ater, and soaked for tw r o 
hours in a 1 : 1000 solution of bichlorid; they 
are then rinsed in sterile w r ater and are ready 
to be filled. 

A saturated solution of salt is prepared by 
adding . six heaping tablespoon fuls of salt to a 
quart of water; this is boiled for an hour. To 
make physiologic salt solution three teaspoon- 
fuls of the saturated solution are added to each 
quart of sterile water. 

Bottling. — A sterile glass funnel is packed 
w T ith sterile gauze and cotton. The salt so- 
lution is strained through this into sterile 
glass flasks. The top of each flask is cov- 
6 



82 GYNECOLOGY FOR NURSES 

ered with non-absorbent cotton and sterile 
gauze, which is tied securely around the neck 
of the bottle. 

After being filled the flasks are boiled for two 
hours in the saline boiler. This is a fish-kettle, 
twenty inches long and eight inches deep; it holds 
three bottles. 

Forty to fifty bottles of sterile salt solution are 
kept on hand; three bottles are heated for each 
major operation. 

Preparation of Supplies. — Sterile Clothes for 
Patient. — The patient wears the following gar- 
ments on the operating table: undervest, drawers, 
nightdress, stockings, abdominal dressing, straight 
binder, sterile sheet. 

These articles are wrapped in one package and 
sterilized together. 

Supplies needed for one major operation: 
8 packages of towels, 6 in a package. 
6 packages of square gauze. 

ioo medium sponges. 
50 small sponges. 

2 sheets for the patient. 

20 strung sponges: 10 large, 10 small. 
1 package large sponges. 
1 sterile sheet for the instrument table. 
6 or 7 operating gowns. 
\ dozen bibs. 

1 package of head gauze, 7 in a package. 
1 package of cotton balls. 
1 package of cotton sticks. 
Tubes of gauze packing, plain and iodoform. 
1 abdominal dressing. 

3 or 4 strips of adhesive plaster, two inches 
wide and fourteen inches long. For Alexander 
operations 6 strips are required. 

Square Gauze. — A layer of gauze 3 inches thick 
is cut into squares 4 by 4 inches. Each bundle 
of squares is wrapped separately. 



MAJOR GYNECOLOGIC OPERATIONS 



83 



Medium sponges measure 7 by 8 inches folded. 
To make a medium sponge, take a piece of gauze 
18 inches square. Fold down one edge of the 
square (a) for about one inch, fold over edges c 
and d for about 5^ inches (Fig. 42). Fold down 
edge e for about 4 inches. Fold the raw edges at 
b up toward e and slip them through the flap 







c 


\ 




3 




a 


e 


I 


d 





L 



Fig. 42.— Method of folding a medium gauze sponge. 

formed by e. The resulting folded sponge has no 
raw edges. 

Small sponges measure 8 by 10 inches unfolded, 
4 inches square folded. They are made like the 
above. 

Large sponges are made like the medium and 
small sponges, from a piece of gauze measuring 
34 by 18 inches before folding, n by 8 inches after 
folding. 

Large Strung Sponges (Fig. 43). — Fold a strip 



8 4 



GYNECOLOGY FOR NURSES 



of yard-wide gauze in half lengthwise and cut 
off pieces 31 inches long. Turn down each .end 




Fig. 43. — Medium sponge and large strung sponge. 

of the piece about 2\ inches, and fold the piece in 
half lengthwise. With a large needle and coarse 
cotton run together the ends and one long side of 
the sponge. Finish the sponge by running through 
one corner a thread of soft knitting cotton, about 
14 inches long; knot the ends of the thread forming 
a loop. 

Small Strung Sponges. — Take a strip of gauze 
21 inches long and 18 inches wide. Turn down 
each end one-half inch, and fold the strip in three 
lengthwise. Stitch the two ends and one long side, 
turning in the raw edges. Run a loop of thread 
through one end, as in the preceding. 

Head Caps. — These are made of unbleachec' 
muslin after the pattern of a simple bathing 
cap. 

Laparotomy Sheets. — These measure one and 
one-quarter yards square. 

An abdominal dressing consists of one large 
sponge, two medium sponges, and one-third of a 
package of square gauze. 

Sterilization of Supplies. — All the supplies 
are folded, wrapped securely in muslin, labeled, 



MAJOR GYNECOLOGIC OPERATIONS 85 

and put in the steam sterilizer under fifteen pounds' 
pressure. They are sterilized three times, for two 
hours each time, and are dried by dry heat. 

The green-soap paste used for scrubbing the 
hands is packed into glass jars within half an inch 
of the top and boiled for twenty minutes. 

Sterilization of Utensils.— Sterilize in the 
utensil sterilizer for twenty minutes five oval 
basins, ten round basins (assorted sizes), three 
pitchers, four instrument trays, three buckets, and 
two specimen pans. 

Preparation of Rooms on the Day of Opera- 
tion. — The operating-room nurse has charge of 
this preparation. 

Doctors 1 Dressing-room. — Lay out on the bed 
the proper number of operating suits. . 

Ether izing-r 00m. — Arrange the catheterizing 
outfit on a small table, the hypodermic outfit on 
another small table, and the etherizer's outfit on 
the large table. When the patient is anesthetized 
in the operating-room these preparations must 
be made there. 

Test the oxygen tank, put fresh sterile w T ater in 
the glass bottle connected with it, and boil the 
nose-piece before each operation. 

Bath-room. — The instrument passer and sponge 
nurse scrub up in this room. Prepare two sta- 
tionary wash-bow T ls for them, supplying nail-files, 
brushes, and sterile green-soap paste. 

Scrubbing-room. — Cover the window-sills with 
sterile towels; on one lay out a package of head 
gauze, a package of sterile bibs, the proper num- 
ber of sterile gowns in packages, and rubber 
aprons, if required. On the other place one large 
oval basin containing sterile towels, and a second 
basin for the set of sterile gloves in their envelopes. 
Place with these a sterile powder shaker contain- 
ing equal parts of boric acid and borax sterilized 
twice in the autoclave. 



86 GYNECOLOGY FOR NURSES 

On the washstand place three jars of green-soap 
paste, three nail-files, and a jar of bichlorid solu- 
tion i : 8000, containing six hand-brushes which 
have been sterilized by boiling for twenty min- 
utes. 

Place three oval solution basins on the low shelf 
in this room. These basins are twenty inches 
long and six inches deep, so that the hands and 
forearms can be completely immersed in the 
solutions which they contain (Fig. 44). When 
the operator arrives on the floor, fill the first 
basin with 70 per cent, alcohol, the second with a 




Fig. 44. — Oval solution basin. 

hot solution of bichlorid 1 : 8000, the third with 
hot sterile water. 

Operating-room. — Put on a pair of rubber-gloves 
and wipe off all the furniture of the operating- 
room with a.i : 20 solution of carbolic acid. This 
done, remove the gloves and arrange the furni- 
ture. 

Roll the operating-table under the electrolier, 
with its head end toward the window and about 
four feet away from it. Cover the table with a 
pad made of two blankets and a sheet folded to 
fit. On a shelf under the table place a pan to 
catch any overflow. Place the two footstools 
under the table and the etherizer's stool between 
the table and the window. Arrange the small 
tables as shown in the accompanying illustration 
(Plate II). 



MAJOR GYNECOLOGIC OPERATIONS 87 

Now disinfect the hands and spread a small 
sterile sheet over the instrument table, and sterile 
towels over the small tables, benches, stools, and 
shelves. 

Instrument Table. — On the upper shelf place 
two instrument pans; on the lower shelf, two trays 
for the specimens removed. 

Scrubbing Table. — Place on this one package 
of square gauze, an atomizer containing tincture 
of iodin, 5 per cent., a basin of bichlorid solution 
1 : 8000, a basin of sterile water, a package of 
sterile towels (8), two sterile sheets for the 
patient, an abdominal dressing, and adhesive 
plaster for the abdomen. 

Sponge Table. — Place the sterile supplies on the 
lower shelf: 

x package of large gauze, 10 in a pack. 

l package of large, strung sponges, 10 in a pack. 

1 package of small, strung sponges, 10 in a pack. 

4 packages of medium sponges, 25 in a pack. 

5 packages of small sponges, 10 in a pack. 
Place on the upper shelf: 

1 basin for dry sponges. 
1 basin for wet sponges. 

6 to 8 sponge forceps. 

Basin Rack. — Place on this the first assistant's 
hand-basin and a basin for large wet sponges. 

Hypodermic Table. — Place on this a box contain- 
ing hypodermic tablets in vials, a solution of 
adrenalin 1 : 1000, spirit of camphor, normal liquid 
digitalis, amyl nitrite perles, ergotol, and a solution 
of caffein citrate made according to the following 
formula : 

K . Caffein. citrat gr. x 

Sod. salicyl gr. xvij 

Aquae des't f^ij. 

Four-ounce bottles containing 95 per cent. 



88 GYNECOLOGY FOR NURSES 

alcohol, distilled water, aromatic spirit of ammo- 
nia, whisky, and vinegar. 

Three medicine glasses: one for sterile water, 
one Tor alcohol for disinfecting the barrel of the 
syringe, and one for camphor or whisky if re- 
quired. 

Two hypodermic syringes and needles. 

One package of square gauze. 

The oxygen tank stands beside this table. 




Fig. 45. — Tray with hypodermoclysis outfit. 

Hypodermoclysis Table. — Place on this one 
bottle of hot salt solution, one of cold salt solution, 
and an empty graduated bottle for mixing. 

Arrange in a sterile tray (Fig. 45) the sterile 
hypodermoclysis needle, rubber tubing, and glass 
funnel. 

Place on this table also alcohol and square gauze 
for disinfecting the patient's skin, a package of 
sterile cotton sticks, one of cotton balls, and col- 
lodion for sealing the wound. 

On the high bench place two sterile pitchers 
filled with hot sterile water, each covered with a 
sterile towel; one sterile basin containing bichlorid 
solution, a dipper, and a thermometer; two sterile 
basins — one is used for water for *he surgeon's 



MAJOR GYNECOLOGIC OPERATIONS 



8 9 



hands and is placed on a small stool on the sur- 
geon's left hand as soon as the operation com- 
mences ; the other is used for changing with this. 




Outfit for stimulating enema. 



The supplies for the stimulating enema are 
placed on this bench — a one-quart glass graduate, 
a glass funnel, four feet of rubber tubing, a glass 
connector, and a soft-rubber catheter No. XII 
(Fig. 46). Boil these articles for three minutes 
before and after using, and keep in a sterile basin. 
The routine stimulating enema consists of one 
quart of hot salt solution, one ounce of whisky, 
and twenty grains of ammonium carbonate. 

Place on the low bench three sterile buckets, one 
for carbolic acid solution, 1 : 20; one for bichlorid 
solution, 1 : 10,000; and the third for cold sterile 
water. 

These buckets are taken from the utensil sterilizer 
with sterile hands and are placed upon the bench. 
Each lid is covered with a sterile towel, pinned on 
with sterile hands upon a sterile sheet. This 
covering serves to remind the nurse that the lid 
must not be laid down upon an unsterilized surface, 
but must be held in one hand while the solution is 
being dipped out. 



9<D GYNECOLOGY FOR NURSES 

Cover the radiators with clean sheets pinned to 
fit. On one lay two blankets and a suit of clothes 
for the patient after operation. 

Place a pail for soiled sponges at the foot of the 
operating table. 

Preparation of Instruments, Needles, and 
Suture Material. — These are prepared by the 
surgical supervisor. She wraps the knife-blades 
in cotton, threads the needles through a gauze 
sponge, wraps them in a towel with the scissors, 
and boils for five minutes. 

The other instruments are wrapped in a towel 
and boiled for twenty minutes in soda solution. 

Silk and silkworm-gut are boiled alone in plain 
water for twenty minutes. 

The glass tubes containing prepared catgut are 
boiled with the instruments for twenty minutes. 



LIST OF INSTRUMENTS FOR ABDOMINAL OPERA- 
TIONS 

2 scalpels. 

i pair straight scissors, 
i pair curved scissors, 
i pair peritoneal scissors, 
i short anatomic forceps, 
i long anatomic forceps. 

2 rat-toothed forceps. 

i pair small retractors. 

i pair large retractors. 
12 straight hemostats. 
12 curved hemostats. 

3 fine-pointed hemostats. 
2 curved clamps. 

2 straight clamps. 

4 tenaculum forceps, 
i volsellum forceps. 
6 sponge clamps. 

i bladder sound. 






MAJOR GYXECOLOGIC OPERATIONS 9 1 



2 needle holders. 
1 applicator. 




Fig. 47. — Instruments for abdominal operations: 1, Peri- 
toneal scissors; 2, small retractor; 3. large retractor; 4, aneur- 
ism needle; 5, cyst forceps; 6, Sampson clamp: 7, toothed 
retractor; S, blunt hook retractor; 9, spud; 10, small curved 
trocar; n, large trocar and rubber tubing. 

i short probe. 
1 long probe. 
1 Grooved director. 



/' 




r\ 




1 

Fig. 48. — Xeedles for abdominal operations. 

i blunt dissector. 

Aneurism needles, one left, one right (Fig. 

47, 4). 



92 GYNECOLOGY FOR NURSES 

Small curved trocar. 

Large trocar and rubber tubing. 

Cyst forceps. 

Spud. 

2 toothed retractors for Alexander's operation 
(Fig. 47, 7). 

2 blunt hook retractors for Alexander's opera- 
tion. 

2 Sampson clamps for panhysterectomy (Fig. 
47, 6). 

Needles: cutting edge, straight, and curved; 
round edge, curved, and subcuticular (Fig. 

48). 

LIST OF SUTURE MATERIAL FOR AN ABDOMINAL 
OPERATION 

Plain catgut: No. o, 2 tubes. 

No. 1, 2 to 5 tubes. 
No. 11, 2 to 5 tubes. 
No. in, 2 tubes. 
Chromicized catgut: No. o, 2 tubes. 
No. 1, 5 tubes. 
No. 11, 2 to 5 tubes. 
No. in, 2 tubes. 
Surgical silk: One glass spool of No. o, 1, 11, in, 
IV : each spool containing 2\ yards of silk. 
Silkworm- gut: 12 strands. 

The instruments and suture material are lifted 
from the sterilizer by the towels in which they are 
wrapped; the knives, scissors, needles, silk, and 
silkworm-gut are placed in one tray; all the other 
instruments in another tray, and both trays are 
filled with cold sterile water. The instrument 
passer removes the towels and proceeds to arrange 
the instruments, thread needles, etc. 

Preparation of Rubber Gloves. — The gloves 
are freely powdered on both surfaces with equal 
parts of sterile boric acid and borax. The 
gauntlet of each glove is turned up one inch. 



MAJOR GYXECOLOGIC OPERATIONS 



93 



They are arranged in crash envelopes (Fig. 49) 
with the name of the wearer plainly designated 
on each envelope. Five pairs of gloves consti- 
tute a set for every section case. 

Sterilization. — Place envelopes containing one 
set of gloves in a towel, close package securely, 
put in autoclave and sterilize thirty minutes at 
fifteen to twenty pounds' pressure; resterilize 
for same time and same amount of pressure with 
dry heat, and the gloves are ready for use. If 
dry sterilization is not used, the gloves in their 
envelopes are boiled five minutes in sterile water 
and lifted into the glove pan, which is filled 
with sterile water. 




Fig. 49: — Gloves, glove envelop, and basin. 

Duties of the Operating-room Nurse During 
Operations. — While the surgeons are scrubbing, 
open a package of medium sponges and one of 
small sponges and drop them into a basin. on the 
sponge table. 

When the patient is wheeled into the operating- 
room, help lift her upon the table, pin her hands 
above her head, and arrange the blankets. Fold 
a single blanket in half lengthwise and lay it across 
the patient's chest, with the lower border reaching 
to the abdominal dressing; tuck the ends under 



J 



94 GYNECOLOGY FOR NURSES 

the patient's back and arms. Fold another single 
blanket lengthwise and cover the lower limbs; let 
one edge reach the pubis and turn the other up 
under the patient's feet; wrap the blanket snugly 
around her feet and legs. 

When the second assistant is ready to scrub 
the abdomen, remove the abdominal dressing 
and hand the package containing the two sterile 
sheets which are used to cover the blankets. 
The skin of the abdominal wall from ribs to sym- 
physis and flank to flank is now sprayed with 
tincture of iodin, 5 per cent., after which hand 
the package of sterile towels. 

Place a hand-basin on the stool beside the sur- 
geon, fill it with hot sterile water, also the empty 
basin on the sponge table, and both basins in the 
basin rack. Watch these basins throughout the 
operation, and when the water in any one of them 
becomes bloody or cold, remove the basin and 
immediately replace it by another filled with fresh 
sterile water. 

Prepare and give all hypodermics ordered during 
the operation, roll up the oxygen tank when 
required, receive the specimens upon specimen 
trays, and place these on the floor at one end of 
the room. 

As the operation draws to a close collect the 
soiled sponges, arrange them in piles on a towel 
spread upon the floor, and count them, reporting 
the count to the sponge nurse and to the supervisor. 

Receive all messages and report them to the 
supervisor, do not leave the room unless directed 
to do so by the supervisor. 

At the end of the operation wheel in the stretcher; 
bring the warm clothes and hot blankets from the 
radiator, help to change the patient's clothes and 
to lift her upon the stretcher, accompany the 
patient to her room, and help lift her into bed. 

Duties of the Sponge Nurse During Opera- 



MAJOR GYNECOLOGIC OPERATIONS 95 

tions. — Preparation for the Operation. — Remove 
nurse's cap, cover the hair with a sterile cap, roll 
the sleeves up above the elbows; take a scrubbing- 
brush and scrub the hands, forearms, and elbows 
for fifteen minutes with hot water and green-soap 
paste. Pass the hands and arms through the dis- 
infecting solutions, counting 120 while holding 
them in the bichlorid. Put on' a sterile gown and 
a pair of rubber gloves. If the gloves are dry 
sterilized, the hands must be thoroughly dried on 
a sterile towel and freely powdered with sterile 
glove powder. Pick up each glove by the up- 
turned gauntlet and draw on the hand carefully. 
When both gloves are on, adjust the fingers and 
turn the gauntlets down over the wrists. Do not 
touch the glove fingers with your ungloved hand. 
When the gloves are sterilized by boiling, put the 
left glove on first; pick the glove up full of sterile 
water, hold it in the right hand, and push the left 
hand down into it, displacing the water. After 
both gloves are on, squeeze the excess of water 
out from the finger-tips up. 

Stand between the sponge table and the first 
assistant; you have charge of three basins: one 
for medium and small, dry sponges; one for wet 
sponges — medium, small, and mounted; and one 
for large and small strung sponges (wet) . 

Upon entering the operating-room the operating- 
room nurse drops a package of medium and one 
of small sponges into the first basin, and hands 
open packages of strung sponges, large and small; 
from the first package take three large strung 
sponges; from the second, six small strung sponges, 
and drop them into the basin of sterile water on 
the basin rack. 

Mount six sponge-forceps with small sponges 
neatly folded. 

When the operator is ready to make the incision, 
lay a medium sponge on the sterile towel covering 



96 GYNECOLOGY FOR NURSES 

the patient's knees; as soon as this sponge is picked 
up, put a fresh one in its place; throughout the 
entire operation see to it that there is always one 
fresh medium sponge lying on the towel ready for 
use. 

After the abdominal incision is made and the 
examination of the cavity completed, strung sponges 
will be called for. These are used to pack away 
the intestine and must be very hot. Lift a large 
strung sponge from the basin of hot water, squeeze 
it dry, and hand it to the assistant; a second large, 
strung sponge may be needed, or several small 
ones may be called for. Keep count of the number 
of strung sponges in the abdominal cavity. 

When a mounted sponge is called for, take one 
from the basin of sterile water, squeeze it dry, and 
hand to the assistant; immediately prepare another 
and have it ready to pass when the first is laid 
aside. Usually four or five mounted sponges are 
called for in rapid succession. As soon as one is 
laid aside remove it from the sterile towel; throw 
away the soiled sponge; remount with a fresh 
sponge, and place in the basin of sterile water. 

The sponge nurse must know how many pack- 
ages of small and medium sponges have been 
opened; this number, multiplied by twenty-five, 
or the number of sponges in each package, will 
give the total number of sponges which must be 
on hand at the end of the operation. As the 
operation draws to a close the soiled sponges are 
counted by the operating-room nurse; the number 
of unused sponges is given by the sponge nurse 
and, if this number corresponds with the total 
number used, the count is correct. If it does not 
correspond, a careful search is made for the missing 
sponge upon the floor; several recounts are made, 
and the fact of a missing sponge is reported to the 
surgeon. 



MAJOR GYNECOLOGIC OPERATIONS 97 

Duties of the Surgical Supervisor at Opera- 
tions. — The surgical supervisor assists the sur- 
geons in putting on their sterile gowns. She helps 
lift the patient upon the operating-table and ele- 
vates the ta,ble into the Trendelenburg position 
when required. 

She administers hypodermoclysis when it is 
ordered; while the incision is being closed she 
gives the stimulating enema. 

At the end of the operation she lowers the table 
from the Trendelenburg position, and after the 
abdominal incision has been closed, hands a basin 
of salt solution and sprays the suture line with 
tincture of iodin, 5 per cent., and finally hands 
the abdominal dressing and adhesive plaster. 
The adhesive plaster has previously been torn in 
appropriate strips and has been fastened on a 
towel. She assists in wiping the patient dry and 
in changing her clothing, and helps lift her upon 
the stretcher. 

Throughout the operation she supervises and 
directs her assistant nurses; reports messages to 
the surgeon; verifies the sponge count; brings 
additional instruments and supplies, if required; 
and resterilizes any instruments that may have 
become soiled during the operation. 

After Operation. — The surgical supervisor attends 
to the instruments and gloves. 

The instruments are taken apart and washed in 
cold water, with gauze, until all blood is removed; 
they are then boiled ten to thirty minutes in soda 
solution; scrubbed with warm water and "bon 
ami" until bright; dried with gauze; polished 
with a chamois and powdered pumice, and returned 
to the dust-proof cabinet. After a knife has been 
used twice it is sent to the instrument shop to be 
sharpened. 

The gloves are first washed in cold water to 
remove all blood-stains and organic matter before 



98 GYNECOLOGY FOR NURSES 

the gloves have become dry. They are then 
washed thoroughly inside and out in warm soap- 
suds containing a small amount of ammonia, 
rinsed in clear tepid water, and boiled in sterile 
water for three minutes, after which they are 
placed on a rack to dry with the gauntlet down. 
After drying on both sides they are mended, 
powdered, arranged in pairs according to size, 
each pair is wrapped separately in a gauze square 
and placed in its respective envelope. 

The operating-room nurse collects the bloody 
clothing and towels in one package and the wet 
clothes in another package; both are sent to the 
laundry. She gathers up the sponges, puts them 
in a pail in the hopper, and lets cold water run over 
them until they are free from blood; this washed 
gauze is used for dust-cloths and for waste purposes. 

All the enameled ware utensils used in the opera- 
ting-room are cleaned with green-soap mixture and 
Sapolio. 

After pus cases the furniture is wiped off with 
carbolic acid solution and the room is fumigated for 
twenty-four hours. After clean cases the floor 
is mopped with soap and water and the entire 
operating suite is put in perfect order as speedily 
as possible. 

Emergencies Which may Arise During Major 
Operations. — The chief emergencies which may 
arise during major operations are respiratory fail 
ure, hemorrhage, and shock. 

The symptoms of respiratory failure are cyanosis, 
shallow respiration, and finally complete arrest 
of respiration. This condition is exceedingly grave, 
and the underlying cause must be discovered 
promptly and removed. 

The immediate treatment consists in removal 
of the anesthetic, swabbing out the throat to remove 
mucus, hypodermics of atropin and strychnin, 
and oxygen inhalations. The most severe forms 



MAJOR GYNECOLOGIC OPERATIONS 99 

require inversion of the patient and artificial res- 
piration. 

The symptoms of respiratory failure are apt to 
recur. The nurse must watch the patient closely 
after she has been put to bed, and must send for 
the physician promptly if cyanosis and shallow 
respirations persist. Oxygen inhalations must be 
continued until consciousness is regained. 

Hemorrhage may be sudden, as from a severed 
artery or large vein, or may be gradual, as from the 
oozing of broken adhesions. 

The symptoms are feeble, frequent pulse, 
shallow respirations, pallor and coldness of the 
skin, and pinched features. 

The treatment of hemorrhage is both local and 
general. The surgeon seizes the cut vessel with 
a hemostat, or makes pressure upon it with the 
fingers or a sponge until a ligature can be thrown 
around it and tied. 

Diffuse oozing may be arrested by pressure with 
hot sponges. 

The general treatment of hemorrhage consists 
in the administration of salt solution by hypoder- 
moclysis or intravenous injection and in the direct 
transfusion of blood. 

Technic of H y pooler mod y sis. — In women, salt 
solution is most readily injected into the fatty 
tissue under the mammary gland. The supervising 
surgical nurse uncovers one breast and disinfects 
the skin with alcohol. She is handed a basin 
which contains the hypodermoclysis outfit — hypo- 
dermoclysis needle, six feet of rubber tubing, and 
glass funnel. Salt solution is poured into the fun- 
nel until it runs out through the needle; the flow 
is then stopped by pinching the tubing. The 
nurse lifts the breast toward the sternum with 
one hand, while with the other she grasps the needle 
and pushes it through the skin into the fatty tis- 
sue between the gland and the chest-wall. The 



IOO 



GYNECOLOGY FOR NURSES 



needle must be inserted in an upward and forward 
direction, so that the point cannot enter the pleural 
cavity. As soon as the needle is in place the salt 
solution is allowed to flow; the funnel is held about 
two feet above the table, and is kept filled with 
salt solution. Each breast will hold about a quart. 
After removing the needle the opening is sealed 
with collodion and cotton. 

Surgical shock is a condition of profound physi- 
cal depression occurring during or after an opera- 
tion. 

PULSE, TEMPERATURE AND BLOOD PRESSURE CHART 

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Fig. 50. — Temporary shock chart, showing fall in blood-pressure. 

The symptoms are pallor of the skin, lividity 
of mucous membranes, feeble, frequent pulse, 
rapid and shallow respirations, low blood-press- 
ure, cold perspiration, and subnormal tempera- 
ture. 
. The symptoms of shock are caused by exhaus- 



MAJOR GYNECOLOGIC OPERATIONS IOI 

tion of the vasomotor center. This leads to accu- 
mulation of blood in the abdominal viscera and a 
relative emptying of the blood-vessels of the rest 
of the body, especially of the brain. 

The following factors predispose to surgical 
shock: prolonged operation, extensive manipula- 
tion or exposure of the intestines, hemorrhage, 
injury to the nerve-trunks, and enfeebled con- 
stitution. 

The symptoms of shock may appear during an 
operation or at any time within the first twenty- 
four hours thereafter. 

The treatment of shock requires energy and 
patience; it must be directed along the following 
lines : 

i. The body heat must be maintained by hot 
applications, blankets, and hot-water bottles. 

2. The empty blood-vessels must be filled with 
normal salt solution until the circulation is equal- 
ized. The salt solution may be administered 
by hypodermoclysis, intravenous injection, or by 
rectum. The Trendelenburg position, elevation 
of the foot of the bed, and bandaging the extremi- 
ties with flannel bandages help to confine the 
patient's blood to the heart and brain. 

3. Stimulation — strychnin, caffein, cocain, or 
camphor is given hypodermically; oxygen by inha- 
lation; black coffee or whisky and ammonium 
carbonate in salt solution by rectum. 

In the treatment of shock it is important to 
remember that overstimulation does harm. 

DESCRIPTION OF MAJOR OPERATIONS 

Ventrosuspension. — The operation of ventro- 
suspension consists in suturing the fundus of the 
uterus to the peritoneum of the anterior abdominal 
wall. 

Steps in the Operation. — The abdomen is incised 
in the median line, adhesions are broken up, and 
the appendages examined. 



102 GYNECOLOGY FOR NURSES 

The fundus is elevated to the incision and two 
silk sutures are passed through the peritoneum 
on one side of the wound and through the fundus 
of the uterus, then out through the peritoneum 
on the opposite side of the wound. These sutures 
are tied. 

The pelvic cavity is wiped clean and the incision 
is closed. 

After-care. — In order to avoid overdistention 
of the bladder and consequent traction on the 
suspension sutures the patient must be catheterized 
every four hours until able to void. Otherwise 
the usual routine is followed. 

The Gilliam Operation. — The Gilliam opera- 
tion is an intra-abdominal shortening of the 
round ligaments. 

Steps in the Operation. — The abdomen is incised 
in the median line, adhesions are broken up, and 
the appendages examined. 

A stout silk ligature is passed under each round 
ligament. The fascia, muscle, and peritoneum 
on one side of the incision are punctured by means 
of a sharp-pointed hemostat. The silk ligature 
under the corresponding round ligament is seized 
in the bite of this hemostat and is withdrawn, 
together with the round ligament, through the 
punctured opening until the doubled ligament 
emerges upon the surface of the fascia. 

This is repeated on the opposite side; the round 
ligaments are stitched to the fascia and to each 
other, and the abdominal incision is closed. 

The Alexander Operation. — The Alexander 
operation consists in shortening the round liga- 
ments in the groins. 

Steps in the Operation. — An incision is made in 
the groin down to the round ligament, which is 
then drawn forth from its sheath. This is repeated 
on the opposite side. 

When the desired shortening is accomplished, 



MAJOR GYNECOLOGIC OPERATIONS 103 

the round ligaments are stitched to the muscles 
and ligaments forming the inguinal canal; the 
excess of each ligament is cut off and the incision 
is closed. 

The after-care is the same as for ventrosuspension. 

Application of Adhesive Strips. — An additional 
piece of adhesive plaster is required on each side. 
This is applied first to the inner side of the thigh, 
is then carried upward and outward in the direc- 
tion of the incision, to be fastened to the hip, beyond 
the gauze dressing. 

Salpingo-oophorectomy . — Salpingo-oophorec- 
tomy is the removal of an ovary and tube. 

Steps in the Operation. — The abdomen is incised 
in the median line, adhesions are broken up, and 
the appendages are examined. 

The corresponding arteries are ligated, the 
appendages are cut away, the raw edges are sewn 
over, and the incision is closed. 

After complete removal of both ovaries and tubes 
the menstrual periods cease; this phenomenon is 
called the artificial menopause. 

Ovariotomy. — Ovariotomy is the removal of 
an ovarian cyst. 

Steps in the Operation. — The abdomen is incised 
in the median line, adhesions are broken up, and 
the cyst is punctured by a large trocar. The 
walls of the cyst are seized with cyst forceps and 
drawn forth from the cavity to aid evacuation. 

When the cyst is completely emptied, its pedicle 
is ligated and cut through; the collapsed cyst is 
removed, and the abdominal incision is closed. 

Supravaginal Hysterectomy . — Supravaginal 
hysterectomy consists in amputation of the uterus 
on a level with the internal os. 

Steps in the Operation. — The abdomen is incised 
in the median line, adhesions are broken up, and 
the blood-vessels ligated. The peritoneum of 
the anterior surface of the uterus is incised and 



104 GYNECOLOGY FOR NURSES 

pushed down, the uterine arteries are ligated, and 
the uterus is amputated on a level with the internal 

OS. 

The uterine stump is sutured, the cut edges of 
the broad ligaments are united, and the abdominal 
wound is closed. 

Panhysterectomy. — Panhysterectomy is the 
removal of the entire uterus, both body and cervix. 

Steps in the Operation. — The preliminary steps 
of this operation are identical with those of an 
ordinary hysterectomy; it differs from the preceding 
operation in that the entire uterus is cut away, 
together with the upper portion of the vagina. 

Before this can be done two right-angled clamps 
are set below the cervix, grasping the upper part 
of the vagina. The vaginal walls are cut across 
between the clamps, and the uterus and a cuff of 
vagina are removed. Before loosening the lower 
clamp the cut edges of the vagina are seared with 
the cautery. The clamp is now removed, the cut 
edges of the peritoneum are sutured, and the 
abdominal incision is closed. 

Vaginal Hysterectomy. — Vaginal hysterec- 
tomy is complete removal of the uterus by the vagi- 
nal route. 

Steps in the Operation. — The cervix is exposed 
by vaginal specula; it is seized by heavy forceps 
and drawn down toward the vulva; a circular 
incision is made around the cervix at the cervico- 
vaginal juncture, the peritoneum of Douglas' 
pouch is opened, two fingers are introduced, 
adhesions broken up, and the intestines packed 
away with gauze sponges; the peritoneum between 
the bladder and the uterus is opened, the uterine 
and ovarian arteries are ligated, the uterus and 
appendages are cut away, and the vagina is loosely 
packed with gauze. 

Vaginofixation, or the Watkins-Wertheim 
Operation. — This operation is of great value in 



MAJOR GYNECOLOGIC OPERATIONS I05 

the treatment of prolapsus uteri associated with 
extensive cystocele in women past the child- 
bearing period. 

Steps in the Operation. — An incision is made over 
the cystocele and the bladder freed and pushed 
well above the level of the internal os. The dis- 
section is carried further until the vesico-uterine 
fold of peritoneum is felt; this is opened and en- 
larged so that the 1 fundus of the uterus can be 
delivered through it. Three or four catgut 
sutures are now placed, uniting the vaginal wall 
to the anterior surface of the uterus. 

AFTER-CARE OF MAJOR GYNECOLOGIC OPERA- 
TIONS 

During the week succeeding a major operation 
each patient occupies a separate room on the 
major operating floor. These rooms are fur- 
nished simply, without carpets, curtains, or or- 
naments; they must be well ventilated, with- 
out drafts. Each room is disinfected with for- 
maldehyd and permanganate of potash for six 
to twelve hours after being vacated. 

While the patient is in the operating-room the 
bed is prepared for her; the pillows are removed, 
the upper sheet, blankets, and spread are folded 
neatly at the foot of the bed, and hot-water bottles 
are laid upon the under sheet. 

When the patient is brought from the operating- 
room the hot-water bottles are removed and the 
patient, wrapped in blankets, is lifted carefully 
into bed. The hot-water bottles are laid outside 
of the blankets, close to the patient, but not 
touching her — two at each side and one at her feet. 
The bed-clothes are drawn up, the room is dark- 
ened, and the patient is left in charge of her nurse, 
who takes and records the pulse and axillary 
temperature. The patient must not be left alone 
a moment until she fully regains consciousness. 



106 GYNECOLOGY FOR NURSES 

The hot bottles and extra blankets form a verit- 
able hot pack, which aids reaction; the patient may 
remain in this for several hours. As her face 
becomes flushed and her skin warm, the blankets 
and water bottles are gradually removed. 

The patient may lie quietly, passing from ether 
narcosis into a natural sleep, or she may soon 
become restless and make efforts to push back the 
covers and throw out her arms. These move- 
ments must be controlled gently. As conscious- 
ness returns the patient's discomfort increases; 
she may vomit one or two mouthfuls of bile- 
stained fluid, and may complain of " feeling sick" 
or that her " stomach hurts" her, and may become 
quite restless. Her hands and face may be bathed 
in cool water, and her mouth may be wiped out 
with a bit of gauze dipped in ice-water. 

Pain. — If the restlessness continues and the 
patient complains of pain, the surgeon usually 
orders a single hypodermic of morphin sulphate, 
^ grain, with atropin sulphate, ^tto" grain, to be 
repeated once in the first twenty-four hours. 

Owing to its constipating effect morphin can- 
not be given to laparotomy patients after the first 
twenty-four hours. After this time some relief 
of pain may be effected by change of position or 
by an ice-bag over the incision; this may be applied 
after the temperature reaches 99 F., and is kept 
on for forty-eight hours. 

"Gas pains" are relieved by turpentine stupes 
or light flaxseed poultices applied to the epigas- 
trium, and by passing the rectal tube. 

Vomiting. — Vomiting from the anesthetic usu- 
ally ceases within twenty-four to forty-eight 
hours, but may last longer. Early vomiting may 
be relieved by inhalations of oxygen, aromatic 
ammonia, or vinegar. Later, counterirritation, 
as by a mustard paste, over the pit of the stomach, 
is helpful; the patient may be given a cupful of hot 



MAJOR GYNECOLOGIC OPERATIONS 1 07 

water with a soda-mint tablet dissolved in it to 
wash out the stomach, or the stomach-pump may 
be used. 

Position in Bed. — The patient is put to 
bed in the horizontal recumbent position, and 
it is desirable that she should remain in this 
position for the first few hours. As conscious- 
ness returns this becomes very irksome to the 
patient; she may be relieved by pillows under 
the head and back, by drawing up her knees and 
slipping a firm pillow under them; a second pillow 




51. — Fowler's position. 



should be placed under the bed-clothes at the foot 
of the bed to support her feet. 

After the patient is well out of ether she is 
rubbed off with alcohol, her clothing changed to 
a nightgown and undervest opening in front, and 
she is turned on her side; her knees are drawn up, 
and a small pillow is placed between them; her 
back is supported by pillows. After a few hours 
in this position the patient may be again turned 
upon her back or to the opposite side. The more 
comfortable a patient is, the better she will rest, 
and the less need there will be for sedative drugs. 



Io8 GYNECOLOGY FOR NURSES 

Elevation of the Foot of the Bed. — After hemor- 
rhage or in shock it is important to confine the 
blood to the brain centers as much as possible; 
for this purpose the foot of the bed is elevated 18 
inches upon blocks or by means of a mechanical 
elevator. This position may be maintained for 
hours or days, and when the time comes to lower 
the bed to the horizontal, it must be done very 
gradually. 

Fowler's Position. — In this position the head of 
the bed is elevated on blocks or by a bed elevator 
(Fig. 51), or the patient's head and shoulders are 
elevated about 12 inches upon pillows or an inclined 
plane. This is used for cases of septic peritonitis 
or pelvic abscess with vaginal drainage. 

Pulse, Temperature, Respiration. — The pulse, 
temperature, and respiration are recorded every 
three hours for the first three days; afterward 
every six hours in a normal case. As a rule, there 
is a rise of temperature to ioo° or 101 F. on the 
first or second day. This is termed the fever of 
reaction, and is probably due to the absorption of 
an aseptic ferment from the wound. In uncom- 
plicated cases the temperature falls on the second 
or third day and remains near the normal line. If 
the wound or peritoneum has been infected, the 
temperature continues high and may be intermit- 
tent. A rise of temperature at the end of the first 
week usually signifies suppuration in the abdomi- 
nal wound. 

The pulse is quickened twenty or thirty beats 
for the first few days; it falls with the temperature 
if the case progresses smoothly. A rising pulse 
requires close watching. 

The routine stimulation of the first week consists 
of strychnin sulphate, ^ grain, every four hours; 
if the pulse is above 100, normal liquid digitalis, 
3 minims, is given with the strychnin. All medi- 
cation is given by hypodermic until the stomach is 
able to retain water. 



MAJOR GYNECOLOGIC OPERATIONS 109 

Facial Expression.— This is an important aid 
in estimating the patient's condition. A bright, 
natural expression attends normal convalescence; 
a flushed, dusky hue or pinched and anxious 
features point to the presence of complications. 

Use of Catheter. — After ventrosuspension, the 
Alexander operation, and the Gilliam operation 
the patient is catheterized every four hours for the 
first three days; later, every six hours if unable to 
void. 

After other abdominal operations the catheter is 
used once in eight hours. 

A catheterized specimen of urine should be sent 
to the laboratory daily for the first three days after 
a major operation. 

Diet. — Water, hot or cold, is given freely as 
soon as the patient is able to swalloAv. When 
the stomach is settled, feedings of hot tea or broth 
are commenced. Small quantities are given and 
increased gradually. 

Liquid feedings, with the exception of milk, 
are given every two hours for the first three days; 
on the fourth day after operation semiliquid 
diet is given, with feedings at 10, 3, and 8 
o'clock. 

On the seventh day full diet is given, with 
feedings at 10, 3, and 8 o'clock. 

Care of the Bowels. — On the third day after 
operation the bowels are moved by a soapsuds 
enema ; this is repeated on the fourth day, and 
on the evening of the fourth day a laxative is 
given, for example, two lapactic pills; this is fol- 
lowed by 4 ounces of Hunyadi water or citrate of 
magnesia the next morning. 

If there is no result from an enema, and the 
patient is uncomfortable, it may be repeated in 
six hours, or a more stimulating enema may be 
given as follows: 



IIO GYNECOLOGY FOR NURSES 

R. Castor oil, 1 , , , 

Magnesium sulphate, / of each ' * ounce » 

Turpentine 2 ounces; 

Glycerin 4 " 

Soapsuds 1 pint. 

A small rectal tube may be inserted for an 
hour several times a day if there is much flatu- 
lence. 

Removing Stitches and Dressing the Wound. 
— If all goes well, the wound is not touched until 
the seventh to tenth day. 

Preparation. — Have ready for the surgeon a basin 
of hot water, nail-brush, soap, bichlorid solution 
1 : 8000, and a small apron. 

Have ready upon the surgical carriage bandage, 
scissors, a package of sterile towels, pus pan, an 
instrument tray containing sharp-pointed scissors, 
anatomic forceps, probe, glass piston syringe, a 
basin of bichlorid solution and one of sterile water, 
a package of sterile gauze, large folded gauze, 
adhesive plaster, a bottle of benzin and one of 
alcohol, a jar of sterile glycerite of iodoform, and 
narrow, folded, iodoform packing, and tincture of 
iodin. 

Roll the surgical carriage into the patient's 
room when the surgeon is expected. 

Arrange the patient in the horizontal position 
and expose the abdominal dressing. Cut the 
adhesive strips on one side close to the gauze; use 
bandage scissors, and loosen the adhesive by slip- 
ping one finger under it before cutting. Raise 
the upper layers of the abdominal dressing by 
means of the adhesive plaster, and turn the dressing 
back over the side of the bed. 

Open a package of sterile towels and hand 
them to the surgeon, who arranges four towels 
to form a hollow square around the abdominal 
dressing. The surgeon lifts off the remaining 
layers of the dressing and drops them into the pus 



MAJOR GYNECOLOGIC OPERATIONS III 

pan. If the lowest layers are adherent, they 
are loosened by dropping sterile water over 
them. 

The surgeon now takes scissors and forceps, 
cuts the stitch or stitches, and removes them. If 
primary union has occurred, the abdominal wall 
is washed oft with sterile water, and tincture of 
iodin (5 per cent.) is painted along the line of 
incision; a few layers of sterile gauze are laid over 
the incision, and a fresh pad and adhesive strips 
are applied. The old dressing is removed by 
cutting through the plaster strips close to the skin; 
the part fastened to the skin may be left, and the 
new strips applied over them, or the old ones may 
be removed after moistening with benzin or alcohol. 
When this dressing becomes soiled or uncomfort- 
able, the nurse may replace it by a smaller one. 

If the wound has broken down or a stitch abscess 
occurred, daily dressings may be required, with 
saline irrigation and gauze drainage, or 2 per cent, 
iodin paste may be injected into the sinus left 
by evacuation of the pus. 

Getting Out of Bed. — The old rule for major 
gynecologic operations was that the patient should 
remain in bed twenty-one days, and should leave 
the hospital on the twenty-eighth day, in the absence 
of complications. 

Recently the tendency has been to shorten the 
period of staying in bed to fourteen days, seven 
days, or less. Dr. Boldt, of New York, is the 
champion of the short stay in bed. He applies 
a firm cast of adhesive plaster over the abdominal 
dressing and hips, so that all strain is removed 
from the wound, and urges his patients to sit out 
of bed in a rocking chair on the third or fourth day 
after abdominal operations. It is claimed that 
early getting out of bed shortens the period of 
invalidism following major operations, and lessens 
the tendency to phlebitis. 



112 GYNECOLOGY FOR NURSES 

As much can be said in favor of the old method 
as against it. Many a gynecologic case gains 
almost as much from the partial rest cure of con- 
valescence as from the operation itself; and, for 
many a poor ward patient, the hospital affords 
the only opportunity for a rest in bed. It is 
more humane and equally good surgery to keep 
the patient in bed fourteen to eighteen days, 
depending upon the gravity of the operation and 
the patient's general condition. 

The Abdominal Bandage. — Patients with 
heavy or flabby abdominal walls should wear an 
elastic bandage for six months to a year after the 
operation. For patients of average development, 
a surgical corset is desirable. If septic infection of 
the wound occurs, with healing by granulation, 
separation of the scar and a more or less extensive 
ventral hernia will probably result in spite of 
bandaging. 

Convalescence. — Convalescence after an ab- 
dominal operation is rapid or slow, depending 
upon the severity of the operation, the previous 
general health of the patient, and the occurrence 
of complications. 

The average brain- worker may return to work 
within six to eight weeks after operation. Patients 
of the laboring class must wait two to four months, 
and must be directed to avoid lifting heavy buckets 
or tubs for some time longer. 

Every patient should be under a physician's 
care for six months to a year after operation, so 
that any local or general sequelae may be dealt 
with as they arise. 

The period between leaving the hospital and 
returning to work or home duties is best devoted 
to a change of air and scene. A few weeks at 
the shore among healthy strangers soon dispels 
the habit of invalidism. 



MAJOR GYNECOLOGIC OPERATIONS II3 

COMPLICATIONS WHICH MAY FOLLOW ABDOM- 
INAL OPERATIONS 

Secondary Hemorrhage. — This terrible and 
fortunately rare accident results from loosening 
of a ligature on some important vessel. It 
usually occurs in the first forty-eight hours after 
operation. The symptoms are a feeble, frequent 
pulse, gradually lost at the wrist, rapid sighing 
respiration, increasing pallor, cold clammy skin, 
great restlessness, air hunger, and abdominal pain. 
The treatment is immediate secondary operation, 
followed by intravenous transfusion, the applica- 
tion of externa] heat and appropriate stimulation. 

Acute Gastric Dilatation. — This serious con- 
dition has been variously attributed to spasm of 
the pylorus, pressure upon the duodenum, reflex 
paralysis,- etc. The symptoms are persistent, 
effortless vomiting of large quantities of olive- 
green or dark-brown fluid which does not become 
fecal; distention of the upper abdomen with 
no rigidity, little tenderness and considerable 
pain; normal or subnormal temperature, with 
rapid pulse, great thirst, and signs of collapse. 
The treatment consists in emptying the stomach 
by means of the the stomach-tube and keeping 
it empty. The patient's hips are elevated so that 
the stomach and intestines shall gravitate toward 
the diaphragm and a tight binder is applied. 
Rectal feeding must be resorted to for several 
days. 

Septic Peritonitis. — Septic peritonitis is an 
inflammation of the peritoneum resulting from 
infection by pyogenic organisms. 

The infection may be introduced from without 
by means of infected instruments, dressings, 
suture material, or by the hands of the surgeons or 
nurses. It may be carried in from the patient's 
skin, if this has not been properly prepared; or the 
cause may be within the patient's abdomen, in the 
8 



114 GYNECOLOGY FOR NURSES 

form of a collection of pus which, through some 
accident of operation, may rupture and infect the 
peritoneum. 

The earliest symptoms are abdominal pain and 
tenderness on pressure; the abdomen soon becomes 
distended, and vomiting is persistent, the vomited 
matter consisting of a characteristic, greenish 
fluid. 

The temperature rises rapidly, and remains 
near 103 ° or 104 F., or the temperature may 
become irregularly intermittent, high fever alter- 
nating with chills and drenching sweats. The 
pulse is rapid and wiry — 140 to 160; the respira- 
tions are rapid and shallow. There are, at first, 
restlessness and persistent insomnia, followed by 
delirium and finally by stupor. The bowels and 
bladder are emptied involuntarily. 

The prognosis is very grave. 

In the treatment of septic peritonitis the patient 
is kept in Fowler's position; hot poultices and 
fomentations are applied for pain; and strychnin, 
whisky, digitalis, caffein, and nitroglycerin are 
given hypodermically, as indicated. The most 
important part of the treatment of this grave 
complication consists in the administration of 
salt solution by bowel by the drop method. 

Teclinic of Slow Enteroclysis. — The apparatus 
required consists of a soft-rubber rectal tube, con- 
nected by means of rubber tubing and glass con- 
nectors, with a receptacle for salt solution, usually 
a fountain syringe kept warm by hot-water 
bottles. 

The reservoir must be elevated six inches above 
the level of the bed, and the fluid contained in it 
must be kept at 102 F. The rate of flow should 
be one quart the first hour and one pint an hour 
thereafter. The rapidity of the flow is regulated 
by raising or lowering the reservoir. If a feeling 
of tightness or distress is caused, the flow is too 



MAJOR GYNECOLOGIC OPERATIONS 115 

rapid. As a rule, the patient can take five pints 
without discomfort; after this it may be necessary 
to retard the flow or to stop it for a time. 

Constant attention on the part of the nurse is 
essential. 

Post-operative Intestinal Obstruction or 
Ileus. — A knuckle of bowel may slip through a 
hole in the omentum, or under a band of adhesions, 
and become strangulated; the bowel may adhere 
to a raw surface, forming a kink which prevents 
the passage of intestinal contents, or the bowels 
may become adherent among themselves about a 
septic focus. 

The symptoms of intestinal obstruction are 
paroxysmal pain, obstinate constipation, — neither 
gas nor feces pass by rectum, — nausea, and 
vomiting. 

"The contents of the stomach are first ejected, 
later bile, then dark fluid with fecal odor, and 
finally liquid feces" (Howard Kelly). 

The abdomen becomes enormously distended 
and tender. The patient is rapidly exhausted, 
her eyes become sunken, her face pinched, and 
her expression anxious. The temperature remains 
at or about normal, but the pulse is rapid; this 
disproportion between pulse and temperature 
may be the first indication of trouble. 

If the diagnosis is made early, secondary opera- 
tion may save the patient's life. As a rule, by the 
time the diagnosis is established, the patient is so 
profoundly poisoned by absorption from the 
obstructed bowel that she dies in collapse with or 
without operation. 

Femoral Phlebitis. — Inflammation of the 
femoral vein occurs in about 10 out of every 100 
patients convalescing from laparotomies. This 
complication makes its appearance from two to 
three weeks after operation. 

The symptoms are fever, rapid pulse, deep- 



Il6 GYNECOLOGY FOR NURSES 

seated pain along the inflamed vessel, and edema 
of the leg. The vein becomes swollen and hard, 
its walls are thickened, and its cavity is filled with 
blood-clot. 

The danger of phlebitis lies in the possible 
detachment of a portion of blood-clot. This 
emigrating blood-clot is called an embolus; it is 
borne by the venous circulation to the heart and, 
if large, may lodge there, causing sudden death; 
or, if smaller, it may pass through the heart and 
cause death by blocking the pulmonary artery. 

A patient with phlebitis must be kept in bed 
until the inflammation has entirely subsided. 
The limb is elevated, and ichthyol ointment is 
applied on lint along the course of the vein; a long 
narrow ice-bag is tied to the limb outside of the 
lint. 

The nursing of a case of phlebitis is an extremely 
responsible task; the patient must be kept comfort- 
able with as few changes of position as possible; 
she must be assisted in moving, and under no 
circumstance should pressure be made over the 
inflamed vein. 

Convalescence from phlebitis is tedious, usually 
extending over six to eight weeks. Some lameness 
of the extremity may persist. 

Embolus. — An embolus is a fragment of blood- 
clot detached from an inflamed vein. The original 
clot is usually situated in the pelvic or femoral 
veins; a portion of it may be dislodged and carried 
to the heart and pulmonary artery. 

If the embolus is small, it produces symptoms 
of precordial distress, pain, dyspnea, and rapid 
pulse; there may be fever following the attack, 
and more or less cardiac irregularity for a time. 

If the embolus is large, the patient suddenly sits 
up in bed, cries out or gasps for breath, and falls 
over dead in a few seconds. 



THE URINARY ORGANS OF WOMEN 

The urinary organs consist of the kidneys, the 
ureters, the bladder, and the urethra. 

The kidneys are paired organs, situated one on 
each side of the vertebral column, behind the 




Kidneys, ureters, and bladder 



peritoneum. The upper pole of the kidney is 
on a level with the twelfth dorsal vertebra; the 
lower pole, on a level with the third lumbar 
vertebra (Fig. 52). 

Each kidney is about four inches long, two and 
one-half inches wide, one inch thick, and weighs 
four to five ounces. 

117 



n8 



GYNECOLOGY FOR NURSES 



The ureters are two membranous tubes which 
conduct the urine from the kidneys to the bladder. 
Each ureter commences within the kidney in a 
number of small pockets which unite to form a 
dilated sac called the pelvis (Fig. 53); from this 
the ureter proper descends to the bladder as a 
cylindric tube, about sixteen inches long, and 
about the diameter of a goose-quill. 

The bladder is the reservoir for urine; it is a 
musculomembranous sac, situated between the 







Fig. 53. — Section of kidney showing pelvis. 

symphysis pubis and the uterus. When filled with 
urine, the bladder expands and assumes a rounded 
form; when empty, the organ collapses, the upper 
movable portion sinking down into the firmer 
lower portion like the layers of a collapsing cup. 
The moderately distended bladder holds about 
a pint. 

The urethra is a musculomembranous tube, about 
one and one-half inches in length, extending from 
the neck of the bladder to the meatus urinarius. 
It is embedded in the connective tissue between 



THE URINARY ORGANS OF WOMEN 119 

the vagina and the symphysis, and assumes a 
slightly curved direction around the symphysis. 
The average diameter of the urethra is J inch. 

DISEASES OF THE URINARY ORGANS 

Nephritis is an inflammation of the kidney 
substance. 

Pyelitis is an inflammation of the pelvis of the 
kidney. This inflammation may be caused by a 
renal calculus or may result from some ascending 
or descending infection. 

Ureteritis is an inflammation of the ureter. 

Cystitis is an inflammation of the mucous mem- 
brane lining the bladder. The inflammation may 
be diffuse or circumscribed; the trigone, or that 
portion of the mucous membrane immediately 
surrounding the urethral and ureteral orifices, is 
most frequently affected. 

The commonest cause of cystitis is infection 
during catheterization; this is, therefore, a disease 
for which the nurse is frequently responsible. 

The symptoms of cystitis are pain in the bladder, 
vesical tenesmus, frequent and painful urination; 
the urine may be cloudy or bloody, or may be 
perfectly clear. Upon microscopic examination 
it is found to contain pus and bacteria. 

Urethritis is an inflammation of the urethral 
mucous membrane; it is often of gonorrheal origin. 

The symptoms are vesical tenesmus, with fre- 
quent and painful urination. 

Calculi may form in the kidney substance, in 
the renal pelvis, in the ureter, or in the bladder. 
The symptoms produced vary with the location 
of the stone. Renal colic signifies the paroxysms 
of pain attending the passage of a stone through the 
ureter. 

Tuberculosis of the urinary organs begins, as a 
rule, in the renal substance; in time the tubercles 
break down, the germs are carried through the 
pelvis and ureter to the bladder, causing in turn 



120 



GYNECOLOGY FOR NURSES 



tubercular pyelitis, ureteritis, and cystitis. This 
is called a descending infection. 

Gonorrheal infection is the typical ascending 
infection. The urethra is involved first, then the 
bladder, and in rare cases the ureter and pelvis 
of the kidney. 

THE TECHNIC OF CATHETERIZATION, BLADDER 
' IRRIGATION, AND CYSTOSCOPIC EXAMINA- 
TIONS 

Catheterization. — Catheterization is the evac- 
uation of the contents of the bladder by means of 
a tube-like instrument — a catheter. 

This little operation usually devolves upon the 
nurse, and, although seemingly of minor import- 
ance, must be carried out with a thoroughly aseptic 




Fig. 54. — Catheters: 1, Glass; 2, silver; 3, soft rubber; 4, 
elastic. 



technic. Numerous cases of infection of the blad- 
der are traceable to faulty catheterization, and it 
should be a matter of pride and of conscience with 
every nurse to prevent the occurrence of such a 
case in her own practice. 

Catheters (Fig. 54) are made of glass, silver, 
soft-rubber, and elastic fiber. All forms can be 
sterilized by boiling. The glass catheter is pre- 
ferred because it is inexpensive, can be boiled 
repeatedly, and shows at once whether it is clean 
or not. 



THE URINARY ORGANS OF WOMEN 121 

Technic. — Boil a glass catheter for five minutes 
in a shallow instrument tray. While it is boiling 
place a small table to the right of the patient's 
bed, near the foot. Arrange on this a small basin 
of sterile water, one of bichlorid solution i : 10,000, 
a jar of green-soap mixture, and a package of sterile 
gauze, opened. Place the tray containing the 
catheter on the table after boiling. 

Arrange the patient in the dorsal position, drap- 
ing a sheet over her to avoid exposure. Place a 
pus pan on the bed close to the perineum, and, if 
necessary, arrange a drop-light or firmly fixed 
candle in position to illuminate the vulva. 

Scrub your hands for five minutes with hot water 
and soap, then hold them in bichlorid solution for 
two minutes. Standing on the right side of the 
bed, clean and disinfect the vulva with soap and 
water and bichlorid solution 1 : 10,000; use 
sterile gauze or cotton balls, and pay particular 
attention to the mechanical cleansing of the 
vestibule and urethral orifice; ten or twelve pieces 
of gauze or cotton should be used. This finished, 
dip your hands in bichlorid solution once more; 
pick up the catheter wdth the right hand, holding 
your thumb over the open end of the catheter; 
separate the labia with the thumb and forefinger 
of the left hand, and insert the catheter into the 
urethral orifice without touching any other part 
of the vulva (Fig. 55). 

It will be noticed that the bladder end of the 
catheter is slightly curved, to correspond with 
the curved course of the urethra around the sym- 
physis; for this reason the catheter must be intro- 
duced with the concavity of this curve upward; 
it will be found to follow, of itself, a slightly curving 
direction around the symphysis. 

After the catheter has been inserted about two 
inches, remove your thumb from the open end and 
let the urine flow into the pus pan. As the flow 
diminishes make gentle pressure above the sym- 



122 GYNECOLOGY FOR NURSES 

physis until the last few drops have been emptied. 
Reapply your thumb to the end of the catheter, to 
prevent dripping of urine; withdraw the instru- 
ment gently and return it to the instrument tray. 
Beginners frequently make the mistake of in- 
serting the catheter into the vagina instead of 
into the urethra. A thorough knowledge of the 
anatomy of the vulva will prevent this accident. 
If it should occur, the catheter must be reboiled 
before being inserted in the proper place. Never 
catheterize a patient unless the parts are fully 
exposed and under a good light. 




Fig. 55- — Catheterization of the bladder. 

Washing Out the Bladder. — Vesical irrigation 
is the approved treatment for subacute or chronic 
diffuse cystitis. This procedure is usually carried 
out by the nurse, and the same precautions must 
be observed as in catheterizing. In fact, cathe- 
terization is the first step in giving a bladder- wash. 

The apparatus required consists of a one-quart 
enameled ware pitcher, a glass catheter with six 
inches of thin rubber tubing attached, a glass 
funnel about three inches in diameter, to which 
are attached four feet of rubber tubing and a glass 
irrigating nozzle with a point sufficiently fine to fit 
into the rubber tubing on the catheter (Fig. 56). 



THE URINARY ORGANS OF WOMEN 1 23 

Preparation. — Arrange on a small table the dis- 
infecting outfit, as described under catheteriza- 
tion. Boil the above-mentioned apparatus in soda 
solution for five minutes. After boiling, lift out 
the pitcher and fill it with the prescribed solution 
at no° F.; a 1 per cent, solution of boric acid or 
a 2 per cent, solution of ichthyol are used frequently. 
Lift the remaining articles into an instrument 
tray, pour warm sterile water over them, place the 





Fig. 56. — Apparatus for bladder washing. 



tray on the small table, and cover it with a sterile 
towel. 

Place the patient in the cross-bed position, with 
her hips resting upon a Kelly pad. Let the apron 
of the Kelly pad hang over the edge of the bed 
into a clean pail. Disinfect your hands and the 
patient's vulva, spread a sterile towel over the 
Kelly pad. 



124 GYNECOLOGY FOR NURSES 

Technic. — Take the glass catheter with the rub- 
ber tubing attached and catheterize the patient. 
Then take the glass funnel with the rubber tubing 
and irrigating nozzle attached, pour the irrigating 
solution into the funnel until it runs out through 
the irrigating nozzle, pinch the tubing momentarily, 
and connect the irrigating nozzle with the tubing 
on the glass catheter; elevate the funnel about two 
feet above the level of the bed. 

As the solution runs into the bladder pour more 
into the funnel; continue this until the patient 
complains of fulness of the bladder; then lower the 
funnel below the level of the bed and let the fluid 
run out over the apron of the Kelly pad. When 
the fluid ceases to run freely, again elevate the 
funnel and repeat the process until the fluid comes 
out of the bladder clear. 

The two essential features in giving a bladder- 
wash are: to maintain a consistent asepsis and to 
prevent the entry of air into the bladder. The 
latter object is attained by completely filling the 
funnel, tubing, and irrigating nozzle before con- 
necting it with the catheter, and by keeping the 
funnel filled with the solution after the connection 
has been made. 

The presence of an assistant, who can pour the 
solution into the funnel, greatly facilitates and 
expedites this procedure, but is not absolutely 
essential. 

Cystoscopic Examinations. — Articles Required. 
— Instruments (Fig. 57) : One pair sponge forceps. 

Small Sims speculum. 

Conic calibrator. 

Hegar urethral dilators, 
sizes 5 to 10. 

Kelly cystoscopes, sizes 7 
to 12. 

Bladder evacuator. 

Ureteral searcher. 

Alligator forceps. 



THE URINARY ORGANS OF WOMEN 1 25 




Fig. 57- — Instruments required for a cystoscopic exami- 
nation: 1, Sponge forceps; 2, small Sims speculum; 3, Conic 
calibrator; 4, Hegar urethral dilator; 5, Kelly cystoscope; 
6, ureteral searcher; 7, alligator forceps; 8, bladder evacuator. 

Glassware (Fig. 56) : Catheter. 

Catheter with six inches of 

rubber tubing attached. 
Glass funnel with four feet 

of rubber tubing and a 

glass irrigating point 

attached. 




Fig 58. — Glass and enameled ware articles for a cystos- 
copic examination: 1, Evacuatcr; 2, funnel and tubing; 3, 
medicine-dropper; 4, bowl; 5, pus pan; 6, conic urine glass; 
7, small cup. 

Two conic urine glasses. 

Medicine-dropper with 

slender tip and with rub- 
ber cap tied on. 



126 GYNECOLOGY FOR NURSES 

Enameled ware: Bowl to hold under cystoscope. 
Pus pan to receive instruments. 
Two small medicine cups. 
Three small bowls for the dis- 
infecting outfit. 
Supplies: Tube of tiny cotton balls. 
Package of square gauze. 
Sterile cystoscope sheet. 
Package of sterile towels. 
Solutions: Boroglycerin. 

Protargol, i per cent. 
Cocain, 10 per cent. 
Silver nitrate, 3 per cent. 
Equipment. — Cystoscopic examinations are 
carried out on a low treatment table. Place a 
table for instruments on the examiner's right and 
a small table for the disinfecting outfit on the left. 
An electric drop-light is the usual form of illu- 
mination, the light being reflected through the 
cystoscope by means of a head-mirror. An 
electric head-light may be used. 

Preparation for Examination. — Place the instru- 
ments, enameled ware, and glassware in a large 
instrument boiler and boil in soda solution for 
five minutes. 




Fig. 59. — Sand-bag. 

While these are boiling lay sterile towels on the 
instrument table ; arrange the examining table as 
for an ordinary gynecologic examination ; place a 
stool and sand-bag (Fig. 59) for the examiner at 
the foot of the table. 

After the apparatus is sterilized, take the sterile 



THE URINARY ORGANS OF WOMEN 1 27 

sponge forceps, lift the three small bowls out of 
the instrument boiler, and arrange them on the 
small table; pour bichlorid solution 1 : 10,000 into 
one, sterile water into the second, and green-soap 
mixture into the third. Open a package of sterile 
gauze squares and place it upon this table. 

Lift the instruments and glassware from the 
boiler and arrange them on the instrument table 
in the order of use: first the medicine dropper, 
then the catheter, the Sims speculum, calibrator, 
Hegar dilators, according to size, cystoscopes ac- 
cording to size, evacuator, searcher, alligator for- 
ceps, catheter with tubing, funnel with tubing and 
irrigating point. 

Place the two conic glasses en this table, one for 
the drawn specimen of urine, one for the sterile 
sponge forceps. Place the three small cups here 
also; pour into the first a dram of a 10 per cent, 
solution of cocain; into the second, the same 
quantity of a 3 per cent, silver nitrate solution; and 
into the third drop a dozen tiny cotton balls. 

Place here also the bowl to be held under the 
cvstoscope; the pus pan to receive the instruments; 
a bottle containing a 1 per cent, solution of pro- 
targol, and a wide-mouthed bottle containing 
boroglycerin. Boil the borcglycerin before and 
after using; it should be warm when placed on the 
table. 

Preparation of the Patient. — Tell the patient to 
loosen all her belts and to remove her corset; 
if the bowels have not moved well an enema should 
be given; let her void urine just before the ex- 
amination, and give her two glasses of w T ater to 
drink. 

Place the patient on the table in the dorsal 
position. Disinfect the vulva with soap and 
water and bichlorid solution, paying particular at- 
tention to the vestibule and meatus urinarius. 

Catheterize and inject into the urethra a pipet- 
ful of a 10 per cent, solution of cocain. 



128 GYNECOLOGY FOR NURSES 

Turn the patient and arrange her in the knee- 
chest position; push back her clothing and throw 
over her buttocks and thighs a sterile cystoscopic 
sheet. These sheets measure a yard wide by one 
and one-half yards long; the center of each sheet 
is cut out in the form of an oval opening to expose 
the vulva. 

Place a thickly folded towel on the buttocks, and 
let an assistant hold the drop-light upon this towel. 

Darken the room. 

Examination. — The examiner sits upon a stool 
close to the foot of the table. The nurse stands 
on the examiner's right. 

With sterile sponge forceps pick up each instru- 
ment as it is called for, dip it in the warm boro- 
glycerin, and hand it to the examiner. First the 
Sims speculum, then the calibrator or Hegar dila- 
tors, then whichever number of cystoscope is 
called for. 

Hold a bowl under the end of the cystoscope to 
catch any urine that may escape through it. 

After the instruments have been used, receive 
them in a sterile pus pan, so that they may be used 
again during the same treatment, if required. 
After handing the alligator forceps to the examiner 
pick up, with sterile sponge forceps, several tiny 
cotton balls in succession; dip them in silver nitrate 
solution and pass to the examiner. 

Finally the examiner calls for the catheter and 
tubing; pick it up, dip in boroglycerin, and hand to 
the examiner, who passes it into the urethra and 
tells the patient to turn over on her side. Place 
a sterile bowl under the end of the tubing, and, 
after the air and urine cease to bubble out, take 
the irrigating apparatus; fill it with a i per cent, 
solution of protargol; connect the irrigating tip 
with the tubing on the catheter, and let the solution 
run into the bladder. This solution is retained 
and acts as a mild antiseptic. 



THE URINARY ORGANS OF WOMEN 1 29 

Catheterization of Ureters. — For this proce- 
dure prepare the regular cystoscopic outfit, and, in 
addition, the following articles (Fig. 60) : 

Ureteral searcher. 

Ureteral catheters. 

Thumb and forefinger of a large-sized rubber 
glove. 

Sterile test-tubes. 

Small glass graduate. 



<&> 




Fig. 60. — Articles required for catheterizing the ureters: 
1, Ureteral catheter; 2, ureteral searcher; 3, test-tube; 4, glass 
graduate; 5, rubber glove ringers. 



The ureteral catheter is made of a combination 
of silk and rubber; it should possess a slender tip 
and a good-sized eye below the tip; sizes 5, 6, and 
7 are generally used. Each catheter is provided 
with a wire stilet and must invariably be wired when 
not in use; a hollow metal rod forms a convenient 
receptacle for the catheters. 

Prepare the catheters by boiling for two minutes 
without and two minutes with the stilet. Boil 
in a long instrument boiler; never bend or coil tlie 
catheter; lay a towel on the bottom of the boiler 
to prevent the catheter from sticking to it. See 
to it that the wire is pushed well into the tip of the 
catheter, and that it does not project through the 
eye: after boiling, lift the catheters out upon a 
sterile towel. After using, inject bichlorid solu- 
9 



I30 GYNECOLOGY FOR NURSES 

tion through the catheters and boil before putting 
them away. 

Boil the searcher and conic glass with the cysto- 
scopic instruments. Sterilize the rubber glove- 
fingers with dry heat and keep them wrapped in a 
sterile towel ready for use. 

Technic. — The usual cystoscopic examination 
is made first. When the ureteral catheter is called 
for, grasp the wire projecting from the open end 
with one pair of sponge forceps and slip a second 
sponge forceps under the catheter about six or 
eight inches from its tip. 

Never grasp the catheter with the forceps, for 
by so doing the coating is roughened and the 
catheter ruined. 

Standing to the right of the examiner, advance 
the catheter until its tip engages in the funnel 
of the cystoscope. The examiner grasps the cathe- 
ter with the thumb and forefinger of the right hand 
and gently pushes it into the ureter. If the exami- 
ner's hands are not disinfected, the sterile rubber 
finger and thumb are slipped on before passing 
the catheter. As the catheter engages in the ureter 
the wire stilet is withdrawn gradually until, by 
the time the tip has reached the pelvis of the kidney, 
the wire is completely withdrawn. 

After the catheter has been passed, the cystoscope 
is withdrawn; the patient is turned upon her side 
and the conic glass graduate is held under the open 
end of the catheter. 

Irrigation of the Pelvis of the Kidney.— In 
the treatment of pyelitis the pelvis of the kidney 
may be washed out through the ureteral catheter. 

In addition to the outfit required for cystoscopy 
and passing the ureteral catheter the following 
apparatus is required: 

A glass-barreled piston syringe with a .two-way 
stop-cock and a conic tip which fits into the ure- 
teral catheter. 



THE URINARY ORGANS OF WOMEN 131 

A one-pint glass graduate filled with sterile 
normal salt solution colored with methylene-blue. 

Thin rubber tubing, ten inches long, to use with 
the syringe (Fig. 61). 

Technic. — After the ureteral catheter has been 
passed and a sufficient quantity of urine collected 
from the kidney, the syringe is attached to the 
ureteral catheter; salt solution is drawn up into 




Fig. 61. — Articles required for irrigation of the pelvis of 
the kidney: 1, Two-way stop-cock syringe with rubber tubing; 
2, one-pint graduate; 3, glass catheter and rubber tubing; 4, 
ureteral catheter. 



the barrel through the rubber tubing; the stop- 
cock is turned and the salt solution injected into 
the kidney. 

A glass catheter with rubber tubing attached is 
inserted into the bladder alongside the ureteral 
catheter and the solution, after flushing the pelvis 
of the kidney, escapes through this into a bowl. 

After a pint of salt solution has been used, a 
solution of bichlorid 1 : 50,000 is drawn up into 
the syringe, injected into the kidney, and allowed 
to remain in the bladder. Silver nitrate solution 
in varying strengths is often used. 

Patients under treatment for cystitis or pye- 
litis must not lie flat on their backs when they 
return to bed. They should be encouraged to 



132 GYNECOLOGY FOR NURSES 

sit up in bed with the bed-rest, or, if too weak for 
this, some form of Fowler position must be main- 
tained. This postural treatment tends to pre- 
vent ascending infection from the bladder in 
cases of cystitis and facilitates drainage from 
the kidney if this organ has already become 
infected. 






THE RECTUM AND ITS DISEASES 

ANATOMY OF THE RECTUM 

The rectum is a cylindric tube which forms the 
terminal portion of the large intestine. It measures 
six to eight inches in length, and extends from 
the sigmoid flexure to the anus. The rectum 
commences opposite the left sacro-iliac articulation; 
it curves inward to reach the median line, opposite 
the third sacral vertebra, and from this point 
extends downward and forward, following the 




Fig. 62. — Sagittal section showing the direction of the anal 
canal and rectum proper, also the rectal valves. 



curve of the sacrum and coccyx; upon reaching 
the tip of the coccyx, the rectum bends upon itself 
and curves downward and backward for one inch 
and a half to terminate on the skin surface in the 
anus (Fig. 62). 

In order to introduce the ringer or an instrument 
into the rectum, it must be passed from the anus, 
in an upward and forward direction, for about one 
and one-half inches. 

The rectum is in close relation with the vagina, 

133 



134 GYNECOLOGY FOR NURSES 

uterus, and small intestine. It is lined with mucous 
membrane, possesses a strong muscular coat, and, 
at its upper part, a peritoneal covering. 

The portion of the rectum immediately within 
the anus is called the anal canal; it is narrow and 
straight, and measures one and one-half inches in 
length. This opens into a roomy portion, the 
ampulla, which is capable of great distention. 
The lumen of the upper portion of the rectum is 
encroached upon by several crescentic folds called 
Houston's valves, which may offer resistance to 
the passage of the rectal tube. 

The anus is an oval orifice situated in the median 
line, one inch in front of the tip cf the coccyx. 
The anal orifice is guarded by a strong circular 
muscle, the external sphincter ani. 

The blood-supply of the rectum and anus is 
furnished by the hemorrhoidal arteries and veins; 
the hemorrhoidal nerves connect these organs 
with the central nervous system. 

RECTAL ENEMATA 

A rectal injection or enema is a solution thrown 
into the rectal cavity. 

Rectal enemata are classified as cleansing, laxa- 
tive, nutrient, and stimulating. They may be 
given low or high in the rectum in amounts vary- 
ing from several ounces to several quarts. 

Apparatus Required for Giving an Enema. — 
An enameled ware vessel fcr the solution. 

An enameled ware funnel. 

A soft-rubber rectal tube No. 21 American scale 
for low enemata (Fig. 63); No. 12 American scale 
for high enemata. 

Boil the funnel and tube in a basin for five 
minutes before and after using. 

Method of Giving a Low Enema. — If the 
patient is dressed, tell her to remove her corset 
and loosen all bands around the waist. 

Place her in the Sims position on a bed or couch; 






THE RECTUM AND ITS DISEASES 



135 



draw her clothing out of the way; cover her with 
a sheet, and place a pad under her hips for protec- 
tion. The Sims position is used because, in this 
position, the small intestines are carried out of 
the pelvis and the rectal canal is somewhat 
straightened. 

Mix the solution for the enema in the enameled 
ware pitcher. Connect the funnel and rectal 




Fig. 63.— Outfit for giving low enema. 



tube, and pour the solution through them until 
all air is expelled. Pinch the tube and anoint 
its free end liberally with vaselin. Hold the tube 
in your right hand, lift the patient's buttock with 
your left hand, to expose the anal orifice. Tell 
the patient to bear down, — this will relax the 
anal sphincter, — and insert the tube carefully, 
pushing it upward and forward, i. e., toward the 
vagina, until four inches have passed within the 
bowel. 

A well-greased rectal tube inserted in the proper 
direction will seem to slip in of itself. If any 
obstruction is encountered, or if the patient com- 
plains of pain, the tube is not properly inserted; 
you must withdraw it and begin again. 



136 



GYNECOLOGY FOR NURSES 



External hemorrhoids may confuse a beginner; 
when these are present, the anal orifice will be 
found in the center of the protruding mass. If 
in doubt, it is wise to introduce a well-oiled and 
gloved finger into the rectum to determine the 
direction of the anal canal. 

After the tube is inserted release the pressure 
from it; elevate the funnel about 12 inches above 
the level of the bed, and let the solution flow into 
the rectum. Keep the funnel filled with the 
solution (Fig. 64). 




Fig. 64. — Method of giving an enema. Patient in the Sims 
position, rectal tube inserted, connected with a funnel and 
tubing. 



The quantity of fluid which can be given varies. 
As a rule, the patient soon complains of fulness of 
the rectum, but by slowing or temporarily arrest- 
ing the flow, the rectum becomes more tolerant and 
a larger quantity can usually be injected than at 
first seems possible. When the prescribed quantity 
has been injected or sooner, if the patient's limit 
has been reached, arrest the flow by pinching the 
tube, withdraw the tube, and direct the patient 
to hold the solution as long as possible. 



THE RECTUM AND ITS DISEASES 



137 



After receiving an enema, the patient may 
require the bed-pan immediately, but, if possible, 
should retain the solution five or ten minutes. 
Never use force in inserting the tube or in inject- 
ing the solution; neglect of this rule may result 
in serious injury to the patient. 

Method of Giving a High Enema. — Arrange 
the patient in the Sims position as for a low enema. 
Insert the well-anointed rectal tube gently in the 
direction of the anal canal, telling the patient to 
bear down as usual. After two or three inches 
of the tube have passed, it will be felt to change 




Fig. 65. — Patient in knee-chest position. 



in direction, following the course of the rectum 
proper. x\fter inserting a few more inches you 
may feel some resistance to its further passage 
as the tube strikes the lowest rectal valve. When 
this occurs, withdraw the tube for about one inch 
and then advance it again gently, giving the tube 
a slightly twisting direction. If the obstruction 
still does not yield, a little fluid run through the 
tube may suffice to carry the valve out of the way. 
A second and a third slight obstruction may be 
encountered and must be overcome in the same 
manner as the first. Pass eight or ten inches of 
the tube within the anal orifice. 



138 GYNECOLOGY FOR NURSES 

If a pelvic tumor is present, pressing upon the 
rectum, it may be impossible to pass the rectal 
tube above the tumor with the patient in the 
Sims position. Under these conditions it may be 
necessary to place the patient in the knee-chest 
position (Fig. 65), which tends to carry the tumor 
out of the pelvis and balloons the rectum with air, 
which makes the passage of the tube an easy matter. 

Solutions Used for Enema ta. — Cleansing 
Enemata. — Salt solution or soap and water. Give 
at ioo° to 105 ° F. 

The stock soap mixture used for enemata is 
made by boiling small pieces of Castile soap in 
water until a jelly is formed. This mixture is 
kept tightly corked in a wide-mouthed bottle; 
one or two tablespoonfuls added to a quart of water 
makes a solution of the proper consistence. 

Laxative Enemata. — Salt solution; or soap and 
water (one pint) , glycerin (one ounce) , olive oil (four 
ounces), or the following formulae: 

Turpentine 1 dram; 

Magnesium sulphate 2 ounces; 

Water 1 pint. 

Castor oil. ) £ 1 1 

■^r . ' it.* > of each. .. Jounce; 

Magnesium sulphate, j z 

Turpentine 2 ounces; 

Glycerin 4 

Soapsuds 1 pint. 

Give at ioo° to 105 ° F. 

Nutrient Enemata. — Formula 1 : Table-salt, 
15 grains; one raw egg] beef-juice, two ounces, 
and peptonized milk, two ounces. 

2. One raw egg; peptonized milk, three ounces. 

3. Beef-juice, two ounces, and liquor pancreati- 
cus, two ounces. 

Give a cleansing enema of salt solution before 
the first nutrient enema, and repeat before every 
third feeding. 

Inject the nutrient enema high, at a temperature 
of ioo° F.; give four to six ounces at a time, and 






THE RECTUM AND ITS DISEASES 



139 



repeat in six hours. Add a small quantity of pep- 
sin or pancreatin to each enema, to aid assimila- 
tion; if the rectum becomes irritable, add also 
five or ten drops of tincture of opium. The patient 
must lie still for one hour after each enema. 

Stimulating- Enemata. — Black coffee, eight 
ounces, or the following formula: 

Ammonium carbonate 30 grains 

Whisky 1 ounce 

Salt solution 1 quart. 

Give at 105° F.; inject high and hold a pad against 
the rectum after giving the enema. If the sphinc- 
ter is relaxed, elevate the foot of the bed. 

RECTAL IRRIGATION 

Rectal irrigation is a valuable method of treating 
certain diseases of the rectum. 

The apparatus required consists of a funnel, 
rubber tubing, and rectal irrigator; the latter is 
a two-way tube of glass (Fig. 66) or metal, one 




Fig. 66. — Glass rectal irrigator. 

branch of which is attached to the funnel and 
tubing; the other branch is free. 

Method of Irrigating the Rectum. — Arrange 
the patient in the Sims position, as for an enema. 

Connect the funnel, tubing, and irrigating nozzle ; 
pour the prescribed solution into the funnel until 
it runs out through the irrigator; pinch the tubing 
and insert the irrigator in the rectum as you would 
a rectal tube; release the tubing and continue to 



140 



GYNECOLOGY FOR NURSES 



pour the solution into the funnel. After distend- 
ing the rectum the solution will run out through 
the free branch of the irrigator; continue flushing 
until it runs out clear. 

If it is desired to leave some solution in the 
rectum, stop the free end of the irrigator and with- 
draw it carefully while the funnel is full. 

Colonic Irrigation. — This procedure is carried 
out in the same manner as rectal irrigation through 
a colon tube and funnel, by alternately raising 
and lowering the funnel. 

The patient should be in the Sims or knee-chest 
position. 

EXAMINATION OF THE RECTUM 

The rectum is examined by palpation and inspec- 
tion. 

Preparation of the Patient. — Direct the patient 
to loosen all belts and remove her corset. 




Fig. 67. — Instruments for proctoscopic examination: 1, 
Conic rectal dilator; 2, proctoscope; 3, colonoscope; 4, fenes- 



trated rectal speculum; 5, long alligator forceps. 



Give a high enema of soap and water or salt 
solution one or two hours before the examination. 

Arrange the patient on the examining table in 
the lithotomy, Sims, or knee-chest position. 

Prepare for the physician a nail-brush, soap and 



THE RECTUM AND ITS DISEASES 141 

water, bichlorid solution, sterile rubber gloves, 
and vaselin as a lubricant. 

Instruments required (Fig. 67): 

Conic rectal dilator. 

Proctoscope. 

Colonoscopy 

Fenestrated rectal speculum. 

Long alligator forceps. 

If thie electric proctoscope or reflected light is 
used, darken the room after the patient is in 
position. 

DISEASES OF THE RECTUM 

Proctitis. — Proctitis is an inflammation of the 
rectum. The inflammation may be catarrhal, 
suppurative, or membranous. 

The causes of proctitis are mechanical or chemical 
irritation and infection. 

The symptoms are weight and fulness in the 
rectum; constant straining and the frequent dis- 
charge of mucus, blood, or pus; at first, constipa- 
tion; later, diarrhea. 

The local treatment of proctitis consists in rectal 
irrigation and the application of medicated solu- 
tions by injection or through the proctoscope. 

Hemorrhoids or Piles. — The word hemor- 
rhoid is derived from a Greek word meaning 
" flowing with blood." Pile is derived from a 
Greek word meaning a ball or globe. 

Hemorrhoids or piles are varicose tumors of 
the lower rectum, characterized by a tendency 
to bleed and protrude (after Gant). 

Hemorrhoids are classed as external or internal, 
according to whether they protrude through the 
anus or not. Each pile consists of a group of 
dilated veins covered with mucous membrane. 

The causes of hemorrhoids are constipation, the 
erect posture, and the absence of valves from the 
rectal veins. 



142 GYNECOLOGY FOR NURSES 

The symptoms of hemorrhoids are bleeding, 
protrusion, rectal tenesmus, and constipation. 

The curative treatment is surgical, and consists 
in removal of the tumors by the clamp and cautery 
or by excision. 

Prolapse of the Rectum. — Prolapse of the 
rectum is a downward displacement of some 
portion of the rectum through the anal orifice. 

The causes of prolapse of the rectum are fecal 
impaction, proctitis, diarrhea, and whooping- 
cough. 

The symptoms comprise the protrusion, through 
the anus, of a dark-red, soft mass, which can be 
replaced; a sense of weight and fulness in the 
rectum, straining, and a more or less irritating 
discharge. 

The treatment is surgical. 

Anal Fissure. — An anal fissure or painful ulcer 
of the rectum is a superficial, slit-like ulcer, situated 
at the junction of the rectal mucous membrane 
and the skin. 

The symptoms of anal fissure are severe rectal 
pain, rectal tenesmus, and constipation. 

The causes are constipation or injury while 
inserting a suppository or rectal nozzle. 

The treatment consists in regulating the bowels, 
stretching the anal sphincter, incision or excision 
of the ulcer. 

Stricture of the Rectum. — Stricture of the 
rectum is a narrowing of its lumen. 

The causes are syphilitic, tubercular, or malig- 
nant ulceration of the rectum, with cicatrization. 

The symptoms are constipation, which may be 
absolute or may alternate with diarrhea from 
ulceration, pain, discharge of pus and blood, 
emaciation, and irregular fever. 

The treatment of simple stricture consists in 
gradual dilatation by bougies; malignant stricture 
is treated by wide excision of the rectum or by the 



THE RECTUM AND ITS DISEASES 



143 



formation of an artificial anus through the opera- 
tion of colostomy. 

Ischiorectal Abscess. — An ischiorectal abscess 
is an abscess situated in the ischiorectal fossa or 
space between the rectum and the tuberosity of 
the ischium on each side. 

The causes of ischiorectal abscesses are falls, 
injury by syringe nozzles, ulceration and stricture 
of the rectum, suppuration of the pelvic organs, 
glands, and bones. 

Symptoms. — The onset may be acute, with a chill, 
followed by a rise of temperature, rapid pulse, 
coated tongue, and headache. 

The local symptoms are pain and tenderness, 
heat and throbbing in the rectum, increased by- 
defecation. 

The affected side is swollen and tender; the 
overlying skin appears red and shining. 

The treatment is surgical, and consists in free 
incision, irrigation, cauterization, and gauze drain- 
age. 

Anal Fistula. — An anal fistula is an unhealthy, 
tube-like passage between the rectum and the sur- 
face of the body near the anus. Anal fistulae are 
always secondary to perirectal abscess. 

Symptoms. — The presence of an opening near 
the anus from which pus, blood, and fecal matter 
is discharged. Localized pain and tenderness. 

The treatment is surgical, and consists in free 
division or excision of the fistula. 

Cancer of the Rectum. — About 4 per cent, 
of all cancers occur in the rectum. 

The cause of cancer of the rectum is not known. 

Early in the course of the disease the bowel is 
thickened, and a stricture may be formed by the 
projection of nodular masses into its lumen; later 
ulceration occurs. 

The symptoms are weight and fulness in the rec- 
tum; frequent desire to stool; alternate constipation 



144 GYNECOLOGY FOR NURSES 

and diarrhea; the passage of mucus, pus, and blood; 
in some cases, severe pain. 

The treatment is surgical, and consists in wide 
excision of the rectum or in colostomy with the 
formation of an artificial anus. 

RECTAL OPERATIONS 

Preparation for Rectal Operations. — Twenty- 
four hours before operation give the patient a low 
enema of two quarts of soap-suds. Six hours 
before operation give a high enema of salt solution — 
one quart. Four hours before operation irrigate 
the rectum with permanganate solution i : 2000, 
until the solution comes away clear. 

Anesthetic. — The shorter rectal operations may 
be performed under cocain or nitrous oxid anes- 
thesia, but, as a rule, general anesthesia by ether is 
used. 

Preparation on the Table. — After the patient is 
anesthetized, place her on the operating table in 
the lithotomy position, with her hips resting on a 
Kelly pad. 

Expose the perineum and draw on the leglettes as 
for a minor gynecologic operation. Wash the 
perineum with soap and water and disinfect with 
bichlorid solution. 

Operation for Anal Fistula. — Steps in the 
Operation. — The sphincter is dilated with a conic 
dilator, and the rectal mucous memorane is in- 
spected for the internal orifice of the fistula; when 
this is found, a fistula probe is passed along the 
fistulous tract from the external to the internal 
opening, a bullet-tipped grooved director is passed 
along the course of the probe, and brought out 
through the anal orifice. 

The tissues overlying the grooved director are 
cut through with a stout knife, the fistulous tract 
is cureted or excised, and the wound is packed 
with gauze. 



THE RECTUM AND ITS DISEASES 



145 



Instruments required (Fig. 68) : 

Conic rectal dilator. 

Fistula probe. 

Bullet-pointed grooved director. 

Knife. 

Hemostats. 

Curet. 

Rat-toothed forceps 

One pair straight, sharp-pointed scissors. 

One pair curved, sharp-pointed scissors. 

Catgut No. i for tying vessels. 

Irrigating can, tubing, and nozzle. 




Fig. 68.' — Instruments required for excision of an anal 
fistula: i, Conic rectal dilator; 2, spoon curet; 3, 4, scissors; 
5, knife; 6, rat-toothed forceps; 7, hemostats; 8, bullet-pointed 
grooved director; 9, fistula probe. 

Dressings. — Apply a thick pad of sterile gauze 
over the packing and hold in place by a T-bandage. 

After-care. — Catheterize every eight hours if 
required. Change the outer dressings when 
soiled. The packing is removed after twenty- 
four hours, when the wound is irrigated and 
repacked. 

Diet. — Liquid and semiliquid for the first week, 
full tray after the seventh day. 

Bowels. — Give a half-ounce of castor oil on the 
fifth day, follow by a soap-suds enema. 

The Clamp and Cautery Operation for 
Hemorrhoids. — Steps in the Operation. — The 



z 



146 



GYNECOLOGY FOR NURSES 



sphincter is dilated and the hemorrhoids exposed; 
a single hemorrhoid is grasped by pile forceps and 
the junction of skin and mucous membrane at its 
base is incised, the clamp is adjusted and screwed 
tight, the pile is cut off with scissors, and its base 
seared with the Paquelin cautery; the clamp is 
removed, bleeding vessels tied, if necessary, and 
the stump is dropped back into the rectum. 




Fig. 69. — Instruments required for the clamp and 
cautery operation for hemorrhoids: 1, Conic rectal dilator; 
2, pile clamp; 3, hemostats; 4, pile forceps; 5, curved scissors; 
6, Paquelin caute y. 



Instruments required (Fig. 69) : 

Conic rectal dilator. 

Pile forceps. 

Curved, sharp-pointed scissors. 

Pile clamp. 

Paquelin cautery. 

Hemostats. 

Catgut No. 1. 

Dressings. — Press a wedge-shaped compress 
of sterile gauze against the anus and hold in place 
by a T-bandage. 

After-care. — The pain during the first thirty- 
six hours is relieved by morphin. 

Give liquid and semiliquid diet during the first 
week. 



THE RECTUM AND ITS DISEASES 



147 



Give a laxative, e. g. y four ounces of Hunyadi 
water, on the fourth day after operation, and a 
soap-suds enema when there is desire for a move- 
ment. Repeat this daily for four days. 

Bathe the anus with very hot water every morn- 
ing and evening. 

Keep the patient in bed one week. 

Ischiorectal Abscess. — Description of Opera- 
tion. — Under general anesthesia the fluctuating 
mass is freely incised, its cavity cureted, irrigated, 
and tightly packed. 




Fig. 70. — Instruments required for the evacuation of an 
ischiorectal abscess: 1, straight scissors; 2, curved scissors; 
3, knife; 4, anatomic forceps; 5, hemostats; 6, spoon curet. 



Instruments required (Fig. 70): 

Knife. 

Hemostats. 

Spoon curet. 

Anatomic forceps. 

Straight, sharp-pointed scissors. 

Irrigating can, tubing, and nozzle. 

Dressings. — Apply a thick pad of sterile gauze 
and a T-bandage. 

After-care. — This is the same as after the opera- 
tion for anal fistula. 

Secondary hemorrhage may follow any rectal 



I4 8 GYNECOLOGY FOR NURSES 

operation; as a rule, the loss of blood is sudden and 
profuse, occurring on the fifth to eighth day after 
the operation. 

The symptoms are those of internal hemorrhage, 
pallor, restlessness, feeble frequent pulse, and sub- 
normal temperature. There may be rectal ten- 
esmus and, rarely, the evacuation of thin blood. 

The occurrence of such symptoms at any time 
after a rectal operation must be reported to the sur- 
geon at once. 






INDEX 



Abdominal bandage, n: 
dressing. 84 
operations, complications. 

113 

instruments for, 90 
suture material for, 92 
Abscesses, ischiorectal. 143 
operation for. 147 
of Fallopian tubes, 50 
ovarian, 50 
pelvic, 50 

vaginal evacuation. 72 
tubo-ovarian, 50 
vulvovaginal. 37 
evacuation. 63 
Acetabulum, anatomy. 12 
Adhesions of clitoris. 38 
Alexander operation. 102 
Amenorrhea. 22 
Ampulla of rectum, 134 
Amputation of cervix uteri. 

67 

Anal canal. 133, 134 
fissure, 142 
fistula. 143 

operation for. 144 

Anatomy. 11 

Anteflexion of uterus, 41 

Anteversion of uterus. 41 

-Anus, anatomy. 134 

Ascending infection of urin- 
ary organs. 120 

Astringent vaginal douches. 

Atresia of vagina, 40 



Bartholinian glands, ducts 

of. 15 
Basin rack, preparation, 87 



Bath-room, preparation, 85 
Bed. elevation of foot of, 108 

for examination, prepara- 
tion. 25 
Bier's hyperemia. 54 
Bladder, anatomy. 11S 

emptying. 24 

irrigation. 122 
Bowels after operations, 109 

emptying. 24 



Calculi, 119 

Cancer of rectum, 143 

of uterus, 43 
Caps, head, 84 
Carcinoma t a of vulva, 38 
Caruncle of vulva. 38 
urethral, s^ 
removal, 62 
Carunculae myrtiformes. 15 
Catheterization of bladder. 
109 
of ureters, 129 
technic, 120 
Catheters, 120 
ureteral, 129 
Cervix uteri, amputation, 67 
dilatation of. 64 
diseases of. 40 
injuries of. 40 
lacerations of. 40 
polypi of. 41 
Chancre of vulva. 39 
Chancroid of vulva. 39 
Clamp and cautery opera- 
tion for piles, 145 
Cleansing genitalia. 24 
rectal enema, 138 
vaginal douches, 34 

149 



y 



i5° 



INDEX 






Clitoris, adhesions of, 38 
anatomy, 15 
smegma of, 38 

Clothing of patient for 
examination, 24 
for operation, 82 

Coccygodynia, 13 

Coccyx, anatomy, 13 

Colonic irrigation, 140 

Colporrhaphy, 67 

Condylomata of vulva, 39 

Convalescence, 112 

Corpus luteum, 19 
cyst, 49 

Cross-bed position for ex- 
amination, 26 

Curettage, 64 

Custadenomata, papillary, 

5°. . 
Cystitis, 119 

Cystocele, 40 

operation, 68 
Cystoscopy, 124 

apparatus for, 124 

preparation for, 126 
of patient, 127 

technic, 128 
Cysts of vagina, 40 

ovarian, 49 

vulvovaginal, excision, 64 



Depleting vaginal douches, 

34 
Dermoid cysts of ovaries, 

Descending infection of urin- 
ary organs, 120 
Diet after operation, 109 
Dilatation, acute gastric, 

113 
of cervix uteri, 64 
Disinfecting intra-uterine 
douche, 36 
vaginal douches, 34 
Disinfection of genitalia, 24 
Doctor's dressing-room, 80 

preparation, 85 
Dorsal posture, 28 



Dorsal posture, elevated, 28 
Douches, 31 

intra-uterine, 34 
articles for, 34 
disinfecting, 36 
for hemorrhage, 36 
preparation, 35 
vaginal, 31 
articles for, 32 
astringent, 34 
cleansing, 34 
depleting, 34 
disinfecting, 34 
emollient, 34 
for hemorrhage, 34 
preparation, 32 
solutions for, 34 
technic, 33 
Dressing wound, no 
Dressing-room, doctor's, 80 

m preparation, 85 
Dysmenorrhea, 22 
drugs for, 52 



Ectopic pregnancy, 48 
Eczema vulvae, 38 
Electricity, 55 
Elevated dorsal posture, 28 
Embolus, postoperative, 116 
Emergencies during major 

operations, 98 
Emergency operations in 

private houses, 76 
Emmenagogues, 52 
Emollient vaginal douches, 

34 
Endocervicitis, 41 
Endometritis, 41 
Enemata, rectal, 134 

apparatus for, 134 

cleansing, 138 

high, 137 

laxative, 138 

low, 134 

nutrient, 138 

solutions for, 138 

stimulating, 139 
outfit for, 89 






INDEX 



151 



Enteroclysis, slow, technic, 

114 - 
Ergot tor uterine hemor- 
rhage, 52 
Etherizing-room for major 
operation, prepara- 
tion, 85- 
major, 79 
preparation, 58 
Examination, gynecologic, 
22 
table, preparation, 25 
External sphincter ani, 134 



Facial expression after 

operation, 109 
Fallopian tubes, abscess of, 

50 
anatomy, 18 
diseases of, 47 
inflammation of, 47 
Female generative organs, 
anatomy, 14 
cleansing, 24 
disinfection, 24 
local applications, 52 
physiology, 20 
urinary organs, anatomy, 

gonorrheal infection 

of, 120 
tuberculosis of, 119 
Femoral phlebitis, postoper- 
ative, 115 
Fibromata of vulva, 38 
Fibromyoma of uterus, 42 
Fistula, anal, 143 
Follicular cyst of ovaries, 49 
Foot of bed, elevation of, 108 
Fourchet, anatomy, 15 
Fowler's position, 108 
Furniture of major opera- 
ting-room, 79 



Gastric dilatation, acute, 

113 
Gauze sponges, 82 



Gauze, square, 82 
Gehrung pessary, 53, 54 
Genitalia, female, anatomy, 

14 
cleansing, 24 
disinfection, 24 
local applications, 52, 
physiology, 20 
Gilliam operation, 102 
Glandular cysts, prolifera- 
ting, 50 
Gloves, rubber, preparation, 

92 
Gonorrhea of vulva, 37-38 
Gonorrheal infection of 

urinary organs, 120 
Graafian follicle, 19 
Gynecologic examinations, 
22 
preparation for physi- 
cian, 22 
of patient, 24 
operations. See Opera- 
tions. 
positions, 27 
treatment, 52 



Head caps. 84 

Hematosalpinx, 48 

Hemorrhage during major 
operation, 99 
douches for, 34, 36 
from uterus, drugs for, 

52 
secondary, 113 

Hemorrhoids, 141 

clamp and cautery opera- 
tion for, 145 

High bench, preparation, 88 

Hodge pessary, 54 

Horizontal recumbent pos- 
ture, 30 

Hydrastis for uterine hemor- 
rhage, 52 

Hydrosalpinx, 48 

Hygiene, 20 

Hymen, anatomy, 15 

Hyperemia, 54 



152 INDEX 

Hypodermic table, prepara- 
tion, 87 
Hypodermoclysis table, 

preparation, 88 
technic, 99 
Hysterectomy, supravagi- 
nal, 103 
vaginal, 104 



Ileus, postoperative, 115 
Ilium, anatomy, 11 
Innominate bones, 1 1 
Instruments for abdominal 
operations, 90 
for examination, 22 
preparation, 90 
table for preparation, 87 
Internal medication, 52 
Intestinal obstruction, post- 
operative, 115 
Intra-uterine douches, 34 
articles for, 34 
disinfecting, 36 
for hemorrhage, 36 
preparation, 35 
Irrigation, colonic, 140 
of bladder, 122 
of pelvis of kidney, 130 
rectal, 139 
Ischiorectal abscess, 143 

operation for, 147 
Ischium, anatomy, 12 
Itching of vulva, s^ 



Kidneys, anatomy, 117 
pelvis of, 118 
irrigation of, 130 
Knee-chest posture, 29 



Labia majora, anatomy, 14 

minora, anatomy, 15 
Lacerations of cervix uteri, 
40 
of perineum, 39 
operation for, 69 
Laparotomy sheets, 84 



Laxative enema, 138 
Leg-holders, 75 
Lengthwise position on bed, 

examination in, 26 
Leukorrhea, 41, 42 
Lipomata of vulva, 38 
Lithotomy posture, 29 
Local applications, 52 

preparation for, 53 
Low bench, preparation, 89 






Major gynecologic opera- 
tions, 77. See also 
Operations, major. 
operating suite, 78 

Megtus urinarius, anatomy, 

I5 . 
Medication, internal, 52 

Menges' bar pessary, 53, 54 

Menopause, 20 
hygiene, 21 

Menorrhagia, 22 

Menstruation, 20 
disorders, 22 

Metritis, 41 

Metrorrhagia, 22 

Minor gynecologic opera- 
tions, 56. See also 
Operations, minor. 

Mons veneris, anatomy, 14 



Navicular fossa, 15 
Needles, preparation, 90 
Nephritis, 119 
Normal salt solution, prepa- 
ration, 81 
Nurses at operation, duties, 

59 
for major operations, 80 
operating-room, duties, 60 
at major operation, 

80, 93 
at minor operation, 
60, 93 
sponge, duties, 94 
supervising, duties, 61, 81, 
97 



INDEX 



153 



Nutrient rectal enema ta, 138 
Nymphae, anatomy, 15 



Oophoritis, 49 
Operating-room nurse, du- 
ties, 60 
for major operation, 

80, 93 
for minor operation, 
60, 93 
Operating-rooms, care of, 57 
major, 78 
care of, 79 
preparation, 85, 86 
minor, 57 

preparation, 58 
Operations, abdominal, in- 
struments for, 90 
complications, 113 
suture material for, 92 
emergency, in private 

houses, 76 
major, 77 

after-care, 105 
bowels after, 109 
catheterization after, 

109 
convalescence, 112 
diet after, 109 
dressing wound, no 
emergencies, 98 
facial expression after, 

109 
getting out of bed, in 
nurses for, 80 
pain after, 106 
position in bed after, 

107 
preparation of patient, 
76 
day before opera- 
tion, 77 
of operation, 77 
of rooms, 85, 86 
pulse after, 108 
respiration after, 108 
sequelae, 113 
stitches in, removal, no 



Operations, major, supplies 
for, 82 
technic, 101 

temperature after, 108 
vomiting after, 106 
minor, 56 

duties of nurses, 59 
in private houses, 74 
preparation of patient, 

P 6 
suite for, 57 

technic, 62 

on rectum, 144 
Organic extracts, 52 
Oval solution basin, 86 
Ovaries, abscess of, 50 

anatomy, 19 

cysts of, 49 

diseases of, 49 

inflammation of, 49 

tumors of, 49 
Ovariotomy, 103 
Oviducts, anatomy, 18 
Ovulation, 20 



Pain after operation, treat- 
ment, 106 
Panhysterectomy, 104 
Papillary cystadenomata, 50 
Papillomata of vulva, 38 
Patient, bladder of, empty- 
ing, 24 
bowels of, emptying, 24 
clothing of, for examina- 
tion, 24 
for operation, 82 
position of, in bed after 

operation, 107 
preparation of, for cystos- 
copy, 127 
for examination, 24 
for major operations, 77 
day before opera- 
tion, 77 
of operation, 78 
for minor operations, 56 
for rectal examination, 
140 



iS4 



INDEX 



Patient, preparation of, for 

rectal operations, 144 
Pelvic abscess, 50 

vaginal evacuation, 72 

inflammation, 50 
Pelvis, anatomy, 11 

of kidney, 118 
irrigation of, 130 
Perineorrhaphy, 69 

after-care, 70, 72 

douches in, 71 

stitches in, care of, 70 
removal, 71 
Perineum, anatomy, 15 

lacerations of, 39 
operation for, 69 
Peritonitis, septic, 113 
Pessaries, 53 

Phlebitis, femoral, postoper- 
ative, 115 
Physiology, 20 
Piles, 141 

clamp and cautery opera- 
tion for, 145 
Polypi of cervix uteri, 41 
Posterior commissure, 15 
Postoperative embolus, 116 

femoral phlebitis, 115 

ileus, 115 

intestinal obstruction, 115 
Postures, 27 

dorsal, 28 
elevated, 28 

knee-chest, 29 

lithotomy, 29 

recumbent, horizontal, 30 

Sims', 30 

standing, 27 

Trendelenburg's, 31 
Pregnancy, ectopic, 48 

tubal, 48 
Private nouses, emergency 
operations in, 76 
minor operations in, 74 
Procidentia uteri, 42 
Proctitis, 141 
Proctoscopic examination, 

140 
Prolapse of rectum, 142 



Prolapsus uteri, 41 
Pruritus vulvae, 38 
Puberty, 20 

hygiene of, 21 
Pubic bone, anatomy, 12 

symphysis, anatomy, 12 
Pulse after operation, 108 
Pyelitis, 119 
Pyosalpinx, 48, 50 



Rectal enemata, 134. See 

also Enemata, rectal. 
Rectocele, 40 
Rectum, ampulla of, 134 

anatomy, 133 

cancer of, 143 

diseases of, 141 

examination, 140 

irrigation of, 139 

operations on, 144 

prolapse of, 142 

stricture of, 142 
Recumbent posture, hori- 
zontal, 30 
Renal calculi, 119 
Respiration after operation, 

108 
Respiratory failure during 

operation, 98 
Retroflexion of uterus, 41 
Retroversion of uterus, 41 
Ring pessary, 53, 54 
Rontgen rays, 55 
Round ligament, shortening, 

102 
Rubber gloves, preparation, 

92 



Sacrum, anatomy, 12 
Salpingitis, 47 

Salpingo-oophorectomy, 103 
Salt solution, preparation, 81 
Sand-bag, 126 
Sarcomata of vulva, 38 
Scrubbing table, prepara- 
tion, 87 
major, 80, 85 



INDEX 



155 



Scrubbing table, major, prep- 
aration, 58 
Scrubbing-up room, 57 
Secondary hemorrhage, 113 
Secretions, normal, drugs to 

replace, 52 
Septic peritonitis, 113 
Sheets, laparotomy, 84 
Shock chart, 100 

surgical, 100 
Sims' posture, 30 
Slow enteroclysis, technic, 

114 
Smegma of clitoris, s^ 
Smith-Hodge pessary, 53. 54 
Sponge nurse, duties. 94 

table, preparation, 87 
Sponges, 8^,, 84 
Square gauze, preparation. 

82 
Standing posture, 27 
Sterilization of rubber 
gloves, 93 

of supplies, 84 

of utensils, 8s 
Sterilizing room. 80 
Stimulating enema outfit, 89 

rectal enemata. 139 
Stitches, removal of. after 

major operation, no 
Stomach, acute dilatation, 

113 
Stricture of rectum. 142 
Strung sponges. 83 
Stypticin for uterine hemor- 
rhage, 52 
Sulphuric acid for uterine 

hemorrhage, 52 
Supervising nurse at major 
operation, 81 
at operation, duties of, 

61 
duties, 97 
Supplies for major opera- 
tion, preparation, 82 
sterilization, 84 
Supply-room, 80 
Supravaginal hysterectomy. 
103 



Surgical shock, 100 
Suture material for abdomi- 
nal operations. 92 
preparation. 90 
Symphysis pubis, anatomy. 

12 
Syphilis of vulva, 39 



Table, examination, prep- 
aration, 2$ 

Tampons for uterine dis- 
placements. s 2 
vaginal, 2^ 

Temperature after opera- 
tion, 108 

Trachelorrhaphy, 66 

Treatment, gynecologic. 52 

Trendelenburg's posture, 31 

Tubal pregnancy. 48 

Tuberculosis of urinary or- 
gans, 119 

Tubo-ovarian abscess. 50 

Tumors of ovaries, 49 
of uterus, 42 
of vagina. 40 
of vulva. 7,8 



Ureteral catheter. 129 
Ureteritis, 119 
Ureters, anatomy, 118 

catheterization of. 129 
Urethra, anatomy, 118 

caruncle, 38 
removal, 62 
Urethritis. 119 
Urinary organs, anatomy. 

diseases of, 119 
gonorrheal infection of, 

120 
tuberculosis of. 119 
Utensils, sterilization, 8>s 
Uterus, anatomy. 17 
anteflexion of. 41 
antero version of. 41 
body of, diseases of, 41 
cancer of, 43 



i56 



INDEX 



Uterus, diseases of, 40 
displacements of, 41 

local applications, 52 

tampons for, 52 
fibromyoma of, 42 
hemorrhage .from, drugs 

for, 52 
inflammation of, 41 
ligaments of, 17 
prolapse of, 41 
retroflexion of, 41 
retroversion of, 41 
tumors of, 42 



Vagina, anatomy, 16 
atresia of, 40 
cysts of, 40 
diseases of, 39 
inflammation of, 39 
local applications, 52 
obstruction of, 40 
tumors of, 40 
Vaginal douches, 31 
articles for, 32 
astringent, 34 
cleansing, 34 
depleting, 34 
disinfecting, 34 
emollient, 34 
hemorrhage, 34 
preparation, 32 
solutions for, 34 
technic, 33 
hysterectomy, 104 
orifice, virginal, 15 
tampon, 23 
Vaginismus, 40 



Vaginitis, 39 
Vaginofixation, 104 
Ventrosuspension, 101 
Vestibule, anatomy, 15 
Vomiting after operation, 

106 
Vulva, anatomy, 14 

carcinomata of, 38 

caruncle of, 38 

chancre of, 39 

chancroid of, 39 

condylomata of, 39 

diseases of, 37 

eczema of, 38 

fibromata of, 38 

gonorrhea of, 37, 38 

inflammation of, 37 

itching of, 38 

lipomata of, 38 

local applications, 52 

mucous patches of, 39 

papillomata of, 38 

sarcomata of, 38 

syphilis of, 39 

tumors of, 38 

warts of, 38 
Vulvitis, 37 

Vulvovaginal abscess, 37 
evacuation, 63 

cyst, excision, 64 
Vulvovaginitis, 38 



Warts of vulva, 38 
Watkins-Wertheim 
tion, 104 

X-rays, 55 



opera- 



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